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

Diagnosis: Mental Health (Anxiety), Central Nervous System/ Neuromuscular Disorder (Dystonic reaction to Risperdal), Respiratory System (difficulty clearing secretions)
Treatment: Inpatient Hospital

Summary: This patient has a history of recently diagnosed anxiety disorder. She had received a Risperdal injection the previous week for that diagnosis. The patient was initially asymptomatic, but developed some rigidity and severe shaking four days after the injection. The patient also complained of some blurred vision. She presented to the Emergency Department (ED) three days prior and was given Benadryl for a possible dystonic reaction and was discharged home with outpatient follow up. The patient's symptoms did not improve and she felt that her muscles were rigid; therefore, she returned to ED. She was treated with Ativan, intravenous (IV) fluids, Benadryl and Benztropine. Vital signs at presentation included a temperature of 36.7C, a heart rate of 95 and a blood pressure of 100/65 mm Hg. The patient was admitted for a dystonic reaction associated with extrapyramidal symptoms (EPS). She was seen by Pulmonary and was admitted to the step down unit for secretion management. As per the history and physical, the temperature was 36.8C, the blood pressure was 123/84 mm Hg, the heart rate was 85 and the respiratory rate was 18. Oxygen saturations were 98%. The patient had cogwheel rigidity, was slow to respond and had muffled speech. She was alert and oriented and in moderate distress. Her lungs were clear. Cardiovascular system heart sounds were S1S2 normal. Her abdomen was soft with some suprapubic tenderness. The white blood cell count was 9.9 K, the hemoglobin was 11.6 g and the electrolytes were within normal limits. Her excessive respiratory secretions resolved after Benztropine.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

The patient remained afebrile and hemodynamically stable after admission. A Pulmonary follow up note indicated that the patient was resting comfortably in no acute distress. Her symptoms entirely resolved. Oxygen saturation was 99%. Her lungs were clear and the abdomen was soft and nontender. The patient was seen by Psychiatry. She was treated with oral Benztropine, Benadryl and Ativan as needed (PRN). Based on review of chart, it appears that this patient had a dystonic reaction to Risperdal. She did not need acute hospitalization. She could have been placed in observation status with diagnostic testing and treatment initiated. The patient improved dramatically with Benztropine and her symptoms cleared up rapidly. She was not hypoxic and her mental status was normal. She was tolerating oral intake. The patient could have been discharged home on oral medications with close follow-up in the outpatient setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: GERD; Hiatal hernia
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

The medical record does not support that inpatient admission was medically necessary for this patient. The care and treatment provided could have reasonably and safely been provided with an outpatient level of care.  This level of care would have permitted overnight hospitalization, post-operative follow up, advancement of diet, and provision of IV fluid, analgesics, and anti-emetics. 

This patient underwent uncomplicated laparoscopic repair of a hiatal hernia and Nissen fundoplication.  There is no clinical documentation to support need for inpatient admission.  The patient remained hemodynamically stable throughout the perioperative period. There was no fever or aberration of vital signs.  This patient's clinical needs could have been satisfied with an outpatient or observational level of care.  The records support that the care provided was clinically appropriate.  It is the level of care (inpatient vs outpatient / observational) that is at issue in this case.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of progressively worsening abdominal pain of 1-week duration. Evaluation included a physical exam, labs, and a computed tomography (CT) scan. She was without a fever at the time of presentation. Heart rate was 92 beats/minute. Lab data identified a white blood cell count (WBC) count of 6.3 thousand (K). The CT scan supported the diagnosis of acute appendicitis. Treatment was initiated with intravenous (IV) fluids and antibiotics. Surgical consultation was obtained.
The patient underwent a laparoscopic appendectomy.  The health plan's determination of medical necessity is upheld.The patient was clinically stable at the time of presentation and remained so during the course of care. Presurgical assessment, operative treatment and post-surgical monitoring could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Coronary artery disease 
Treatment:  Inpatient admission
The proposed treatment, inpatient admission, was medically necessary.

This patient was admitted for an elective cardiac catheterization, and a complex PCI of a CTO was performed.  Dual access was obtained for the procedure.  This type of a PCI would be considered high risk due to the nature of the target lesion, need for dual access, high dye load, risk of dissection, perforation, etc.  Patients such as this one were excluded from the studies of outpatient PCI.  It would be consistent with the current standard of care that this patient, after this complex PCI be managed in an inpatient setting; therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Diverticulitis and abscess
 
Treatment:   Inpatient admission, medication, monitoring
The insurer denied the inpatient admission. The denial was reversed.
The patient had been hospitalized at another hospital for perforated diverticulitis with an abscess.  She had three prior episodes of diverticulitis.  A Computerized Axial Tomography (CAT) scan revealed the perforated diverticulitis and abscess.  The patient was started on intravenous (IV) Zosyn.  On exam, tenderness was present in the lower abdomen without rebound or guarding.  Upon transfer, intravenous (IV) antibiotics were continued.  A repeat CAT scan showed acute diverticulitis with increasing adjacent phlegmonous changes.  A new air-fluid collection was seen compatible with a fistulizing abscess.
Clinical indications for admission for acute diverticulitis (M-150) include a significant abnormality complicating the diverticulitis.  Both a fistula and abscess are listed as significant abnormalities that are indications for admission. 
At the time it was thought the patient required surgery and the services were stated as not available at the prior hospital. This patient had diverticulitis which was complicated by an abscess and fistula.  Intravenous antibiotics were given.  The patient met Milliman Care Guidelines (MCG) criteria for inpatient care even if no surgery was done.  MCG guidelines for admission for acute diverticulitis do not require that there is a plan for surgery.  The patient can be treated under these guidelines with intravenous (IV) antibiotics.  
The carrier's denial of coverage for the inpatient hospital services is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with multiple risk factors and known peripheral arterial disease who underwent peripheral angiography in the setting of symptom limiting claudication who was found to have severe disease of the right superficial femoral artery (SFA). The proximal vessel was treated with percutaneous transluminal angioplasty (PTA) and  drug-coated balloon (DCB) with residual dissection requiring stent placement, and the mid vessel was treated with PTA and DCB alone. The patient was admitted to the inpatient service and discharged the following day without significant event. The health plan's determination of medical necessity is upheld. The patient's peripheral angioplasty and stent placement was performed without complications. The patient was discharged after an uncomplicated overnight stay. Although residual dissection requiring stent placement represents some level of elevated risk, there were no specific treatments rendered nor were there any clinical, procedural, post procedural, electrocardigraphic, hemodynamic, laboratory or other issues that warranted a higher level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems
Treatment: Dental/Orthodontic Procedure (Crown)

Summary: This patient has dental problems. The dentist is requesting authorization for a dental crown on tooth #4.
 
The insurer has denied coverage for a crown on tooth #4 as not medically necessary. The denial was upheld. 

Review of the record indicates a crown for tooth #4 is not medically necessary for this patient. The documentation consists only of a radiograph. There is no letter of medical necessity or photographs. In order to place a crown the tooth must be restorable. There is not sufficient documentation showing the tooth is restorable. The radiograph shows the tooth has had root canal treatment and the crown is missing. There is no documentation that there is sufficient tooth structure remaining above the gingiva to restore the tooth and the radiograph does not show sufficient width available for a crown. This information is required to evaluate the need for a crown. The medical necessity for a crown for tooth #4 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

The patient has medical history significant for seizure disorder, hypertension, attention deficit hyperactivity disorder (ADHD), growth delay, and developmental delay who presented with three-day history of vomiting and fever with Tmax (temperature max) of 103. The patient also reported diffuse abdominal pain, nausea, and cough productive of yellow phlegm. Recent emesis contained flecks of blood. The patient was not able to keep anything down and had decreased urine output. In the emergency department (ED), rapid testing revealed influenza A positive.

The health plan's determination is overturned. The inpatient stay was medically necessary. This patient was admitted with abdominal pain, vomiting, and dehydration in the setting of positive influenza A. While hospitalized, the patient was noted to have a significant murmur, as well as complaints of chest pain, prompting cardiology investigation. The patient was found to have low ejection fraction, indicative of some degree of heart failure. Initially, it was thought that the patient had myocarditis secondary to influenza infection. However, this was not substantiated on MRI. The patient also had long-standing history of hypertension with no known etiology. Multiple specialists were consulted and because of the severity of the heart failure, and the patient was transferred to the Cardiology service on the telemetry unit. The influenza symptoms (vomiting, abdominal pain) resolved fairly quickly even though the patient was not able to tolerate Tamiflu. However, the inpatient cardiac work-up, medically necessary because of the severity of his heart failure, necessitated ongoing hospitalization. The full duration of his hospital stay was medically necessary and appropriate at the acute inpatient level of care. The patient could not have been safely managed at a lower level of care or in the outpatient system.
Appeal type: Medical necessity
Decision: Overturned

The patient has a past medical history significant for bipolar disorder and hypothyroidism who presented to the emergency department because of suicidal thoughts. The patient had been talking about committing suicide for several days preceding the day of admission.

The health plan's determination is overturned. The inpatient stay was medically necessary for this patient. In this clinical case, the patient was admitted with an unstable mental condition, which could potentially result in suicide. This patient required very close monitoring including having a sitter at the bedside, frequent assessments, and monitoring to ensure stabilization of mental condition while receiving therapy.
This is quite a complex task and goes beyond what usually can be achieved at the observation level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health, Alcohol Abuse/Addiction
Treatment: Mental Health: Inpatient, Substance Abuse: Inpatient
  
Summary: This patient was admitted to the hospital due to making a suicide attempt by taking an overdose of pills including 15 Zoloft, Gabapentin, and Naltrexone while drinking several bottles of Four Loko. He reportedly had depressive symptoms including sad mood, low energy, sleeping problems, decreased appetite, feelings of guilt, and he had 4 past reported suicide attempts prior to this one. He reported suicide intent and disappointment that he was not successful in his suicide attempt. He was drinking alcohol and had withdrawal symptoms also including tremors, elevated heart rate of 122, elevated blood pressure of 155/104, vomiting, hyperreflexia, and mild ankle myoclonus. There was suspicion of serotonin syndrome. He had diagnoses of Major Depressive Disorder, Generalized Anxiety Disorder, and Alcohol Use Disorder. He had a recent hospitalization for a suicide attempt with a medical hospitalization and also had a recent psychiatric hospitalization. 

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was reversed.

Suicide attempts are the single most reliable indicator for suicide and this patient had a serious suicide attempt and multiple past and recent suicide attempts. It was reported that he was disappointed that he was not successful in his suicide attempt and he stated that he knew how to be successful next time. Notes reported that he was delirious as he was not oriented to place and it was reported that he was cognitively impaired. It also was reported that psychiatry stated that he required inpatient psychiatric treatment after medically cleared so he was at risk both medically and psychiatrically and considered a high risk patient. Notes reported continued tachycardia and that he was very sad in mood as his mother was diagnosed with ovarian cancer. Notes also reported that he was lonely with no friends, felt unwanted, in addition to being delirious. Notes reported that his Librium taper was continued. Notes reported that he minimized his depression and suicidality to try to get out of the hospital. It was reported that he stated that he would return to drinking and harm himself. Notes reported that he also was taking a slow Librium taper, restarted Zoloft and started Buspirone. Notes reported that he still had withdrawal symptoms including a CIWA of 4-5 and was still taking Librium to prevent worsened withdrawal including life threatening withdrawal. Notes reported that he was at high risk due to multiple past suicide attempts and required inpatient hospital treatment until discharged to a 24 hour rehabilitation treatment for alcohol rehabilitation treatment. This patient could not safely be treated in an outpatient detoxification as he was drinking alcohol and had withdrawal symptoms requiring detoxification treatment and was high risk for suicide.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department (ED) with one-day history of cough and fever (rectal temperature 100.2), and same day history of increased work of breathing.  The patient was admitted for continued monitoring due to a young age and risk of apnea.

The health plan's determination is upheld.  The inpatient stay was not medically necessary.  The risk of apnea in neonates with RSV is not insignificant, but this patient was otherwise hemodynamically stable and non-toxic in appearance.  The patient did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of cirrhosis, morbid obesity, R (right) eye blindness, depression, and hypertension (HTN) who presented to the emergency department (ED) with a chief complaint of alcohol withdrawal symptoms and hematemesis x 4 episodes that day. The patient was given intravenous (IV) lorazepam, ondansetron, and IV fluids and reassessed. He continued with tremors and was deemed unstable for admission to the clinical detox unit and was admitted to general medicine. 

The health plan's determination is overturned in part. The record shows that his nausea and vomiting, tremors, and alcohol withdrawal symptoms were resolved on medication and he had no active bleeding as of the date. He was tolerating oral diet and medications. Liver function tests (LFTs) were elevated but stable and Maddrey's score did not predict a poor prognosis. He remained alert and oriented and able to follow instructions for discharge. Continued stay in the hospital at the inpatient level of care for the dates is not supported by the submitted clinical information and not consistent with accepted standards of medical practice.
Appeal type: Medical necessity
Decision: Overturned

The patient is an adult who presented for inpatient detoxification treatment to address severe substance use disorder with opioid and stimulant class substances of abuse. The patient has a longstanding history of heroin use with more recent use of crack cocaine. He reported a past history of severe withdrawal symptoms when attempting to curtail use, and undergone multiple detoxification and rehabilitation treatments with relapses.

The health plan's determination is overturned. The treatment of this patient's substance use disorder with detoxification and withdrawal management did require the continued structure of an inpatient level setting and 24-hour monitoring in view of the patient's clinical presentation and course of treatment. Additionally, the patient had an extensive treatment history with relapses that supported the necessity for an inpatient level of care, and presented with moderately severe withdrawal symptoms. Withdrawal symptoms were appropriately managed with tapering dosages of methadone requiring monitoring and supportive measures including the availability of nicotine replacement therapy and comfort medications.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The proposed treatment, inpatient admission, was not medically necessary.
This patient presented with chest pain and a history of diabetes mellitus and hypertension.  Utilizing the HEART score, the patient was considered low risk (three points). (1)  Utilizing the TIMI risk score, the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1). (2) 
Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (2).  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], or death) 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. Ultimately this patient underwent myocardial perfusion imaging that revealed no evidence of ischemia- confirming the aforementioned low risk stratification.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. It was reasonable to treat the patient at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Choking; unresponsiveness
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
BRUE, or brief resolved unexplained event, has replaced the term ALTE, or acute life-threatening event. It is defined as brief self-resolved event occurring in an infant less than a year of age, associated with one or more of the following: cyanosis or pallor; absent, decreased, or irregular breathing; marked change in tone; and/or altered level of responsiveness. BRUE is a diagnosis of exclusion. Infants that present for evaluation can be categorized as either high risk or low risk based on careful and detailed history and physical exam. Any abnormalities on exam may place the infant into a higher risk category, with consideration for child abuse if there are inconsistencies in the story or exam, cardiac arrhythmia in the presence of positive family history, and infection if there is fever. To be considered lower risk, the infant must be older than 60 days, gestational age greater than or equal to 32 weeks and postconceptional age greater than or equal to 45 weeks, this must be the first event, the event must have lasted less than a minute, not requiring CPR, with no concerning historical or exam findings. While hospitalization overnight or longer for monitoring and evaluation may not be indicated for lower risk infants, hospitalization and further testing may be indicated for high risk infants. Concerning signs that would warrant hospitalization include toxic appearance, lethargy or respiratory distress at the time of the event, bruising or other evidence of trauma, history of multiple events in the past 24 hours, history of clinically significant events or unexpected death of a sibling, history that raises suspicion for the possibility of child maltreatment, and dysmorphic features or known syndrome. 
This baby presented following a choking episode because he was unresponsive to stimulation. There was concern for possible seizure. While it was not unreasonable to observe the baby with telemetry overnight in the hospital, he was stable, with no fevers or oxygen requirement, remaining hemodynamically stable for the entirety of his stay. He did not require acute inpatient and could have been safely managed at a lower level of care.