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

This is a patient with a history of hypertension and hyperlipidemia. She presented to the emergency department after an episode of burning chest and upper back pain that woke her from sleep and was associated with diaphoresis. The pain lasted for 10-15 minutes and resolved spontaneously. Her physical exam was unremarkable. There were no acute electrocardiographic changes. Her serum troponin level was undetectable. She was treated with aspirin, atorvastatin and pantoprazole and admitted to the hospital to rule out acute coronary syndrome. The health plan's determination is upheld.
This patient presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. On the other hand, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. There is no indication in the records provided that other potentially life-threatening diagnoses were thought to be likely. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Advanced Dementia
 
Treatment:  Increase in Personal Care Assistance (PCA) Service hours Level ll, 24 hours per day, 7 days per week

The insurer denied the Increase in Personal Care Assistance (PCA) Service hours Level ll, 24 hours per day, 7 days per week.  The denial was reversed. 

This is an elderly female who has past medical history of Coronary Artery Disease (CAD), Atrial Fibrillation, hypertension, hyperlipidemia, cerebrovascular accident (CVA), transient ischemic attack (TIA), Alzheimer's disease, dementia, asthma, sleep apnea, multinodular goiter, spinal stenosis lumbosacral region, and Vitamin D deficiency.  The patient is in need of an increase in hours of personal care assistance, due to the worsening in her cognition and her declining health.  It was reported by the patient's family that her mental status has gotten worse since her last hospital admission in early 2019.  She requires assistance with most of her activities of daily living.  She has lost weight and cannot remember to take her medication.  Her behavior has become a safety concern; she almost started a fire while cooking, and she has flooded her apartment 3 times.  She has also flushed inappropriate items down the toilet.  In addition, she can no longer navigate her way causing her to get lost.  It was noted that the patient had declined considerably from her previous UAS-ATSP exam summary from early 2019. 

As per the UAS and UAS-ATSP Summary of Caregiver Info and Tasks from mid-2019, the patient's daughter is the only informal caregiver, and it appears she can provide only limited assistance.  The available records do not identify specific tasks or the length of time during which the daughter can provide assistance on any particular day.  The daughter requested PCA services 24 hours per day, 7 days per week (as per insurer's final adverse determination letter).  It is reasonable to consider that she is requesting 24 hour care because neither she nor any other informal caregivers can provide the needed assistance to the patient on a regular basis.  Assistance from informal caregivers is voluntary as per NYS regulations for personal care services.  Due to the patient's cognitive impairment and other medical conditions adversely affecting her ability to perform IADLs and ADLs, it is medically necessary for her to have caregiver assistance to maintain basic daily activities and help prevent adverse health and safety events.  When informal caregivers cannot provide support, then personal care services are indicated to provide the necessary assistance with IADLs and ADLs, which for this patient includes activities (walking, transfers, toileting/incontinence care) that occur at unscheduled times throughout the day and night. 

The carrier's denial of coverage for an increase in Personal Care Assistance service hours Level ll, 24 hours per day, 7 days per week is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Pneumonia
Inpatient hospital stay

This is the case of a  previously healthy female who presented to the emergency department (ED) with complaints of cough x 6 days, ear pain, and shortness of breath. Patient was seen 3 days prior and diagnosed with left ear infection; a chest x-ray at that time was negative for infiltrate. Patient was given amoxicillin and the last fever was 3 days ago. Past medical history significant for pneumonia, required albuterol. The patient reports no recent travel, and immunizations are up to date. Physical examinations in the ED showed bilateral otitis media (OM), tachypnea with intercostal retractions and poor air movement. Chest x-ray showed opacity in the lingulate lobe, representing atelectasis or pneumonia.  Patient was given albuterol neb x 2, ipratropium neb x 1, oral prednisolone, oral azithromycin, intravenous (IV) ceftriaxone, and intravenous fluids (IVF) bolus. After nebulizer treatments the patient had RR 36, O2 sat 86-87% on room air, improved with 2Liters of oxygen via nasal cannula (NC). The decision was made to admit to the hospital for pneumonia and hypoxia, with failed outpatient antibiotics. HP determination of medical necessity is overturned in whole. The requested inpatient hospitalization is considered medically necessary for this patient. This patient returned to the ED with continued/worsening shortness of breath and difficulty breathing. Patient was noted to have tachypnea, retractions, and hypoxemia that did not improve with breathing treatments and medications provided in the ED; thus, at the time of reassessment this patient required inpatient level hospital care due to her need for oxygen and continued respiratory monitoring. Chest x-ray showed opacity in the lingulate lobe, representing atelectasis or pneumonia.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of adenocarcinoma of the prostate, diagnosed with a biopsy 2 months prior to this presentation, who presented to the hospital previously, with fevers and chills, and ill appearance, at the office visit with the urologist. Reportedly, immediately after the prostate biopsy, the patient had an episode of fevers and chills as well and was treated with an antibiotic therapy consisting of ciprofloxacin, for 14 days. On the day of admission, the patient had a recurrence of the fevers and chills and therefore was admitted to the hospital for further evaluation and management. The patient had gone to an urgent care center prior to this admission, where a urine culture was done and it was negative. Reportedly, he was prescribed antibiotics, which he did not take. The admitting diagnosis is sepsis related to urinary tract infection.

The health plan's determination is upheld. The inpatient stay was not medically necessary. Reviewing the patient's admission based on Milliman Care Guidelines (MCG) criteria for urinary tract infection M-300, the patient does not satisfy acute inpatient admission criteria. There is no evidence of hemodynamic instability, vomiting, altered mental status. The patient has no persistent fever. It does not appear that the patient required parenteral antibiotics beyond observation treatment. There is no evidence of a resistant pathogen or an inability on the patient's part to take oral medications. The last prescription of antibiotics, per the documentation, was not filled by the patient, and the previous treatment before that, occurred immediately after the prostate biopsy, which is separated temporally by 2 months from the current admission. There is no radiographic imaging of pyelonephritis. The patient does not satisfy the sepsis criteria. There is no evidence of ureteral obstruction. There is no evidence of emphysematous pyelonephritis. The patient does not have acute renal failure based on laboratory studies. In summary, the patient presents with symptoms of a UTI and does not satisfy the criteria for sepsis. Therefore, the inpatient hospitalization is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain
Issue under review:  Inpatient admission

Determination:  The Inpatient admission was not medically necessary.

While the patient had a clinical presentation of angina, he was electively admitted for cardiac Cath and possible PCI.  This was performed through the radial artery, with several interventions.  There were no complications noted, and he was sent to overnight care.  He received fluids and standard post-cath medications. 

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care.  This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care.  In this case, the patient underwent a radial catheterization with good results.  He was always hemodynamically stable with normal vital signs.  He was admitted to telemetry and observed overnight.  Echo and EKGs (electrocardiograms) were unremarkable, and provided no evidence of instability. 

The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care.  The only cardiac care provided was telemetry, which is frequently performed in a lower level of care.  The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. 

One of the major advantages of radial artery approach is early ambulation, early discharge and minimal risk of bleeding.  While there was always a potential for an adverse event, one did not happen, and no actual treatment was added.  Unless the clinical situation is unstable, the adding of a 2B/3A glycoprotein inhibitors does not require an extended stay or higher level of care, especially in a clinical situation, such as this patient's, with no bleeding, a radial approach, and no ACS (acute coronary syndrome). 
 
Milliman criteria requirements were not fulfilled, as there was never any evidence of ACS present, bleeding or hemodynamic instability.  All of the testing and therapy that were provided would have been appropriate, safe and guidelines consistent in a lower level of care.  Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cystic fibrosis
 
Treatment: Med Systems Electro Flo 5000 Percussor

The insurer denied the Med Systems Electro Flo 5000 Percussor. The denial was upheld.

This case involves a middle age male with cystic fibrosis.  The patient was recently in the hospital for one month for influenza, rhino/enterovirus, cystic fibrosis exacerbation, and acute hypoxic respiratory failure requiring extracorporeal membrane oxygenation (ECMO).  Once weaned from the ECMO, he was transitioned to oxygen via nasal cannula and was utilizing a percussor with great success.  The physician detailed that given the recent hospitalization and failure of a prior vest due to low lung capacity, the patient was unable to bring up secretions effectively.  The patient had previously utilized the requested equipment and it worked well for him.  At a follow-up visit a couple of months later the patient stated he was doing better and secretions were clear.  The patient was able to move his secretions fine and received manual chest physiotherapy from his wife.  The physician indicated there were no changes to be made.

Restrictive airway disease treatments include modified postural drainage, assisted cough, active cycle of breathing techniques, and oscillatory positive/expiratory pressure devices, in addition to intrapulmonary percussive ventilation.  While literature does support utilization of percussion devices for patients with cystic fibrosis, the request appears to have been made a few months ago. A note from a follow-up visit indicated the patient was able to move secretions just fine and does not detail the use of the requested unit.  Therefore, it is unclear why the patient would need the requested device.  The intrapulmonary percussive ventilator (IPV) therapy received in hospital and listed in the denial is not the same therapy requested. Handheld percussor treatment was found to be no more effective than hand cupping technique.  Further, he currently has an AffloVest, which is standard management.  According to the most recent note, the patient was not having any difficulty with secretions; therefore, the prior denial remains upheld.

The carrier's denial of coverage for Med Systems Electro Flo 5000 Percussor is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

This case involves an adult admitted for acute inpatient psychiatric treatment. The patient was brought to the emergency department for urgent psychiatric care after becoming increasingly anxious in the context of anorexia nervosa with restricted intake. The patient had a history of mood disorder best characterized as severe major depressive disorder and co-morbid eating disorder with anorexia nervosa, restricting type. The patient presented with a decline in functioning and inability to care for self with somatic symptoms including pallor, dizziness and dehydration. Patient had been hospitalized recently with discharge and non-compliance with  outpatient treatment that included medication management and therapy, as patient failed to follow-up with aftercare with worsening symptoms of the psychiatric disorders including panic attacks and poor nutritional intake.
The mental status examination revealed depressed mood with anhedonia and low self-worth. Patient reported morbid thoughts and inability to function. There was no evidence for mania. Sleep, appetite, energy levels and volition were disturbed. Affect was blunted and anxious with pressured speech and poor eye contact. Patient displayed thought blocking with slowed mentation and had suicidal ideation without a plan.
The patient was admitted to acute inpatient level services with close observation, structured milieu therapy, and pharmacotherapy with Effexor, Klonopin and as needed (prn) medications for insomnia supplemented with vitamins and nutritional supports. Meals and intake were monitored with ensure supplements. Patient tended to isolate and was noted to be anergic and withdrawn. Patient began to engage in therapy with improved mood and affect, and more expressive emotion. Intake improved to 75 to 100% of  meals. The patient's eating disorder and co-morbid psychiatric conditions and severity of symptoms warranted the admission for inpatient level services, as proposed. The patient had failed to respond to treatment at a lower level of care despite receiving intensive treatment and services in the context of a recrudescence of symptoms and deterioration in functioning. Moreover, safety concerns, the need for the structure of an inpatient setting, and the intensity of services provided by the acute inpatient program including assistance with meals and basic activities of daily living with active treatment could not have been and could not be effectively provided at a lower level of care. The patient had failed to respond or sustain a response to clinically appropriate, intensive treatment in the community with medication management and therapy; thus, the treatment plan with respect to acute inpatient level care was necessary to address the disordered eating with restricted intake and to manage the anxiety and mood disturbance. The health plan's determination of medical necessity is overturned in whole.
The requested services are medically necessary in this case and is consistent with prevailing standards of professional practice, published practice guidelines, and the scientific literature, referenced below.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a medical history of chronic obstructive pulmonary disease on home oxygen, hypertension, paroxysmal atrial fibrillation on Eliquis, transient ischemic attack, ischemic cerebrovascular accident, gastrointestinal bleeding, and heavy tobacco abuse. She presented to the emergency department with dyspnea, gradually increasing for 6 weeks. Her dyspnea was mild, increased with walking or exertion and improved with rest. Vital signs were notable for a low diastolic blood pressure of 41 millimeters of mercury (mmHg). A computed tomography scan of the abdomen and pelvis showed moderate cirrhotic contour of the liver with a 12 millimeter (mm) enhancing lesion in the right hepatic dome, and 11 mm enhancing lesion in the left hepatic lobe, possibly consistent with hepatocellular carcinoma; magnetic resonance imaging was recommended for evaluation; there were findings consistent with chronic inflammatory changes in the ascending colon and proximal transverse colon, mild diverticulosis, myomatous uterus, mild cellulitis in the lower abdominal wall, and mild anasarca.
She was admitted and placed on telemetry. The health plan's determination is upheld. The patient presented with gastrointestinal bleeding and anemia but did not have tachycardia or persistent hypotension. No cause for inpatient status, such as severe intra-abdominal process, obstruction, perforation, abscess, or toxic megacolon, was suspected or apparent on imaging. The patient had monitoring of clinical status, vital signs, serial labs, imaging, and a Gastroenterology consultation, which were warranted, given history of cardiovascular disease and the potential for ischemia if bleeding resulted in inadequate perfusion. An endoscopy was performed. No severe complications of cirrhosis, such as acute decompensation or hepatic encephalopathy or variceal bleeding, were found. Eliquis, the anticoagulant the enrollee was taking, is not clearly associated with gastrointestinal bleeding, and has a half-life of approximately 12 hours. As hemodynamic status remained stable, and there was no hypotension or hemodynamic decompensation, all of the measures that were undertaken, including labs, monitoring, endoscopy, blood transfusion, and specialist consultations, could have been performed at a lower level of care without the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient has a past medical history of hypertension (HTN), PVCs (premature ventricular contractions) status/post (s/p) ablation, IBS (irritable bowel syndrome), gastroesophageal reflux disease (GERD), nephrolithiasis, cellulitis, remote ETOH abuse, obesity, and a history of colectomy. The patient presented to the emergency room (ER) with shortness of breath, lightheadedness/dizziness and floaters. The patient had no chest pain or shortness of breath. The patient was admitted to the telemetry unit for elevated blood pressure.

The health plan's determination is upheld. This patient's hospitalization was not medically necessary at an inpatient level of care.  This patient had hypertensive urgency. There was no evidence of hypertensive emergency with end organ damage. The patient did not have stroke/TIA, renal failure, congestive heart failure (CHF), chest pain or dyspnea.

According to a review article on the management of hypertensive urgency:
"Although patients with hypertensive urgency are often treated with medications to acutely lower their blood pressure, there is no evidence to support this practice, and a strong pathophysiologic basis suggests that harm may result. "

Furthermore, "National guidelines support a cautious approach to the treatment of hypertensive urgency. The seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of Hypertension, published in 2003, noted that "patients with markedly elevated BP but without acute target-organ damage usually do not require hospitalization, but they should receive immediate combination oral antihypertensive therapy"
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of coronary artery disease, hypertension, fibromyalgia and depression/anxiety who presented to the emergency department with rectal bleeding. On presentation, the patient had a temperature of 36.5, pulse rate of 55, blood pressure of 199/81, respiratory rate 16, and oxygen saturation 99% on room air. Bloodwork was notable for white blood cell (WBC) 5.7, hemoglobin 12.3, and hematocrit 36.7, platelet count 260,000, sodium 141, potassium 4.2, chloride 106, and bicarbonate 24, total bilirubin 0.1, alkaline phosphatase 92, aspartate aminotransferase (AST) 16, alanine aminotransferase (ALT) 24, and albumin 4.0. A computed tomography angiography (CTA) abdomen/pelvis revealed nephrolithiasis and diverticulosis. The patient was admitted to the medical floor and treated with conservative management with intravenous fluid hydration and monitoring of blood counts.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient remained hemodynamically stable throughout the hospital course without ongoing gastrointestinal bleeding. The patient did not require endoscopic therapy or surgical intervention for ongoing gastrointestinal bleeding. Based on Milliman Care Guidelines (MCG) guidelines, the patient did not have active gross bleeding per rectum, failure to control bleeding, unstable comorbid illness, coagulopathy, suspected or known ischemic colitis, previous aortic graft placement, hemodynamic instability, complicated anemia, severe pain requiring inpatient management, absent bowel sounds, intestinal obstruction, low platelet count, severe electrolyte abnormalities, acute renal failure, high fever, require parenteral nutrition or immediate surgery. Therefore, an inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

The patient, according to his parents, fell or rolled off of a bed onto a hardwood floor and sustained a Type 3 supracondylar humerus fracture. The patient was brought to the emergency room and admitted to the hospital and underwent closed reduction and percutaneous pinning. The patient was observed closely for signs of neurovascular compromise. A social worker was asked to see the parents because of concern for non-accidental injury and the home environment. At issue is the acute inpatient admission.

The health plan's determination is overturned. The inpatient stay is medically necessary. A Type 3 supracondylar humerus fracture is an injury that requires urgent management, generally consisting of closed reduction and percutaneous pinning, as was done in this case. There is a significant risk of neurovascular compromise and compartment syndrome, which necessitates close monitoring for a period of time after surgery. In addition, when a supracondylar humerus fracture occurs in a child of this age, there should be concern about the possibility of non-accidental injury, and the surgeon expressed this concern. It is important for the child to remain in the hospital until there is a satisfactory assessment of the circumstances surrounding the injury and the safety of the home that the child will be returning to. For these reasons inpatient hospital admission is justified and essential.