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

Diagnosis: Substance abuse
Treatment: Inpatient substance abuse treatment 

The proposed treatment, inpatient substance abuse treatment, was not medically necessary for this patient.

The admission and the continued inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of bipolar disorder and ongoing substance use disorder with alcohol and cocaine. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted inpatient level treatment. There were no objective symptoms of withdrawal other than tremor or biomedical issues in this case, and the patient had received detoxification treatment recently with discharge two days prior to presenting for another detoxification treatment, as noted in the clinical summary. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder and mental health treatment with a past history of treatment episodes for the co-occurring disorders. Thus, the admission and the continued inpatient admission for detoxification treatment and withdrawal management with 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.

This answer is consistent with New York State OASAS LOCADTR 3.0 Criteria and with established practice guidelines, the scientific literature, and ASAM Criteria, as referenced below.

In this case scenario, the patient was amenable to treatment with lower level care in a less restrictive setting. The patient displayed no serious disturbance of mental status despite having a history of a chronic mental disorder and ongoing substance use disorder with alcohol and stimulant/cocaine. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted continued inpatient level admission and treatment. There were no objective symptoms of withdrawal other than tremor or biomedical issues in this case including normal vital signs throughout the inpatient stay. Thus, the admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario, as the health plan asserts. And, NY State OASAS LOCADTR Criteria are not met for the inpatient level of care, as the patient could have proceeded directly to lower level care in a less restrictive treatment setting as the health plan asserts. The denial of coverage for the inpatient admission and stay is reasonable, and reflects sound medical judgment and is in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Acute Cholecystitis
 
Treatment:  Inpatient Admission

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

This is a female patient who presented to the Emergency Room (ER) with complaints of right upper quadrant pain with two episodes of nausea and vomiting.  It was reported that the patient had a history of gallstones.  The patient received intravenous Zofran, Morphine Sulfate and Toradol.  It was determined that the patient had cholecystitis.  The patient underwent a laparoscopic cholecystectomy without complications.  The patient was discharged home the following day with aftercare instructions. 

According to current literature a patient may be admitted to inpatient services when there is evidence of severe pain requiring acute inpatient management, severe electrolyte abnormalities, the inability to maintain oral hydration, peritoneal signs, or when there is evidence that the patient needs surgery that cannot be performed on an ambulatory basis.   Within the documentation the above was not noted.  The documentation did not detail the patient had any type of severe abdominal tenderness, rebound tenderness, involuntary guarding, or a rigid abdomen.  The documentation also did not detail the patient had signs of a severe electrolyte abnormality, severe pain requiring acute inpatient management, bacteremia with the inability to maintain oral hydration.  While it was noted the patient was admitted to undergo a laparoscopic cholecystectomy, this is typically done as an ambulatory procedure.  

Review Outcome:  The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: supraventricular tachycardia (SVT)

Treatment: inpatient hospital admission

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

This patient is a male child with documented supraventricular tachycardia (SVT) that was taken to the Emergency Room (ER). In total there were three self-resolving episodes of supraventricular tachycardia (SVT). The infant was noted to have Wolff-Parkinson-White (WPW) syndrome on ECG and was admitted to Pediatric Intensive Care Unit (PICU) for monitoring and pharmacological therapy. The insurance company has denied the admission which is being appealed.

After review of the medical record and pertinent medical literature and guidelines this reviewer has determined that the decision to deny the PICU admission should be upheld.  

First of all at 106 days old the patient is not considered a neonate as stated in the appeal letter Reason for Admission: "Neonatal Supraventricular Tachycardia."

The rationale for admission in the appeal letter quotes the MCG 22nd Edition -Supraventricular Arrhythmias-ORG:-510. The appropriate Guideline is MCG 23rd Edition Supraventricular Arrhythmias, Pediatric ORG:P-510. This more recent guideline states indication for admission include "hemodynamic instability" and "persistent symptomatic Tachycardia despite observation care treatment." This infant was hemodynamically stable and during observation in the ER and no further episodes of SVT. (It is noted in the appeal letter that the infant had two episodes of self-resolving SVT while in the ER but the medical record documents these episodes were "prior to ER arrival)."

The decision to begin treatment with propranolol during an observation period was appropriate but the need for admission would only be appropriate as stated in the above MCG Guideline; if the drug had a proarrhythmic potential (i.e. procainamide) which was not relevant in this case.

There is a rationale in the medical record that admission was needed because of the presence of WPW on the electrocardiogram (ECG). The pediatric cardiology literature (reference 2 below) states, that in pediatric patients with WPW the incidence of episodes of SVT decrease over the first year of life and the incidence of sudden death at this age is "minimal."

This patient does not have a significant, serious, congenital heart defect (a normally functioning bicuspid aortic valve) which would necessitate the hospital admission. The health plan acted reasonably and with sound medical judgment, in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Asthma
Treatment:  Inpatient admission

The Inpatient admission was not medically necessary.

This male child with significant atopic disease (multiple food allergies including anaphylaxis with peanut allergy, as well as eczema) presented to the ED with wheezing and throat pain because of parental concern for anaphylaxis.  He had been seen earlier in the day and treated with albuterol and enteral steroids, but symptoms returned.  He was found to have retractions and wheezing on exam responsive to multiple albuterol treatments including continuous albuterol and magnesium.  He was managed overnight in the ED, per parent wishes to avoid admission if possible, but was finally admitted because he was requiring albuterol every three hours. 

However, prior to transfer to the floor, treatments had been changed to every four hours, and he was tolerating with no intervening increased work of breathing.  He was overall hemodynamically stable with no oxygen requirement.  Based on this and his responsiveness to albuterol in the ED, including ability to space treatments successfully to every four hours, he did not require acute inpatient management.  He could have been managed in the ED with close outpatient follow-up, including referral to Pulmonary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  High blood pressure; dizziness
Treatment:  Inpatient admission
The acute inpatient admission was not medically necessary.

The patient presented with transient speech impairment and dizziness.  At presentation, her neurological examination was normal.  Risk stratification for stroke based on her past medication history, presentation and clinical evaluation did not warrant acute admission (Dai et al., 2015).  The diagnostic studies, neurological consultation, monitoring and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is the case of a previously healthy child who presented to the emergency department (ED) with a 2 days history of fever and cough. There was no vomiting, diarrhea, rash, or difficulty breathing. Oral intake was decreased but adequate for liquids.
Vitals in the ED were temperature 103.1 F, heart rate (HR) 139, respiratory rate (RR) 24, and blood pressure (BP) 94/56, with oxygen (O2) saturation of 95% on room air. Weight was 28.5 pounds. Physical exam notes no apparent distress; auscultation revealed decreased breath sounds. Labs showed white blood cell (WBC) count of 7.2 with 60% segs/25% lymphs, hematocrit (Hct) 34, and platelets (Plt) 167. Electrolytes were normal, and Flu and respiratory syncytial virus (RSV) testing were negative. Chest x-ray showed left lower lobe markings consistent with pneumonia. The patient was given ibuprofen, ceftriaxone, and intravenous fluids (IVF); she was admitted to the inpatient ward. The patient remained afebrile and stable on room air. She was discharged home the following day to complete a course of oral azithromycin.

The health plan's determination is upheld.

This is a child with a fever and cough who presented to the ED. She was not toxic appearing. She did not have dehydration by clinical or laboratory criteria (bicarb=20, no vomiting or diarrhea or inability to tolerate oral intake). She initially had a heplock placed and did not require IVF bolus. On arrival the patient was both febrile and tachycardic; respiratory rate was appropriate for age and she did not have hypoxia (O2 sat less than [<] or equal to [=] 92%) on room air. The patient responded appropriately to antipyretic medication with normalization of heart rate. Therefore, based on medical documentation, this child could have been appropriately treated at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Acute pancreatitis
 
Treatment:  Inpatient admission, intravenous fluids, monitoring

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

The patient had been vomiting for three days.  She was having upper abdominal discomfort.  She had a mild tachycardia.  Abdominal tenderness was present without rebound or guarding.  The Lipase level was 1056 (normal up to 78).  A CAT scan showed pancreatitis.

Clinical indications for admission for pancreatitis (M-250) include having acute pancreatitis, as indicated by two or more of the following:  abdominal pain, pancreatic enzymes greater than three times the upper limit of normal, and characteristic abdominal imaging.  In this case, the patient met all three of these indications.

This patient was diagnosed with acute pancreatitis.  She was kept nothing by mouth (NPO) and given intravenous (IV) hydration.  She subsequently left the hospital against medical advice.  However, she did meet MCG criteria for an inpatient admission.  An inpatient hospital admission was medically necessary. 

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

Diagnosis: Bipolar l Disorder
 
Treatment: Inpatient Psychiatric Admission 

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

This is a female patient who admitted to the hospital for inpatient psychiatric treatment. Upon admission she appeared to be decompensating; her symptoms included restlessness, agitation, and anger. She denied thoughts of harming herself or others. She was treated with Librium and Seroquel. The patient expressed that her treatment was helping her. She did continue with episodes of anxiety while hospitalized but did not report any of feeling psychosis, severely depression, or mania. She was discharged safely.

The patient had shown significant improvement in her bipolar symptoms early in her admission.  Notes indicate no evidence of psychosis, acute mania, acute depression, disorganized behavior, acute treatment noncompliance, suicidal ideation or intent, or homicidal ideation or intent.  She could have continued to receive safe and effective treatment on an outpatient basis. 
  
This finding is consistent with the general standards of psychiatric care and the American Psychiatric Association (APA) Guidelines for the Treatment of Patients with Bipolar Disorder. 
 
The carrier's denial of continuation of coverage for the inpatient psychiatric admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures
 
Treatment: Inpatient admission, diagnostic testing, medication

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

This is a young male with a history of seizures and asthma.  The patient was taken to the emergency department after an apparent seizure at home. He was noted to have shaking of his feet lasting for a few seconds. Per the patient's mother, his first seizure was a febrile seizure and since then he continues to have recurrent seizures. The mother stated that the patient takes Keppra every morning and night, but did not have it the morning of this episode. As the patient was preparing for discharge from the ER he began to have another shaking episode. He was admitted to the hospital. A CT scan of the head was negative. His Keppra level was low at 6.1. He remained stable and seizure-free throughout the remainder of the stay.  His Keppra AM dose was increased. The patient did not have any further significant abnormalities and he was discharged.  

According to current literature, a patient may be admitted to inpatient services when there is evidence of hemodynamic instability, complex febrile seizure, the patient is in status epilepticus or there are repetitive seizures that are not controlled with emergent treatment, there is a brain disorder, cardiac arrhythmia of immediate concern, altered mental status, or evidence of a non- focal neurologic deficit.  Additionally, if there is a metabolic disorder persisting despite observation care treatment and recurrent seizures or evidence of intracranial pressure that is increased, a patient may also be admitted.  

The patient had one additional seizure while in the emergency department.  However, there is no indication the patient was appropriate for inpatient services.  The patient could have been monitored at a lower level as he did not have any other abnormal findings.  The patient's objective examination was normal and imaging did not reveal any significant abnormality.  

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

The patient has a diagnosis of Bipolar disorder and schizophrenia who presented due to auditory hallucinations with suicidal ideation with plan. The patient had command hallucinations telling her to run into the street to be killed by ongoing vehicles. The patient had auditory hallucinations and active suicidal ideation. The health plan's determination is overturned. The patient had active suicidal ideation with a plan and command hallucinations. The patient has a diagnosis of bipolar disorder and schizophrenia and presented due to auditory hallucinations with suicidal ideation with plan.  She had command hallucinations telling her to run into the street to be killed by ongoing vehicles. She had auditory hallucinations and active suicidal ideation.   She had 1:1 supervision, command hallucinations that were ongoing and causing anxiety.  The patient was acutely agitated, threw a board game at another patient and threatened to hurt staff members to the point that security was called and required intramuscular (IM) Ativan and IM Benadryl.
Appeal type: Medical necessity
Decision: Overturned

The patient is a female with acute lymphocytic leukemia (ALL), cervical cancer, hyperlipidemia, chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), and basal and squamous cell cancers who presented with acute onset dyspnea and dry cough that had lasted for 6 days. Symptoms were initially felt to be from pleural effusions, but a thoracentesis draining 1 liter (L) of sanguineous fluid the day prior had afforded no relief. Persistent symptoms following thoracentesis led to a computed tomography pulmonary angiogram (CTPA) that found multiple pulmonary emboli (PEs), so she was sent to the emergency department (ED).

A heparin drip was started given the recent sanguineous effusion, and she was admitted. By the next day symptoms were improved, and oncology recommended repeating the chest x-ray (CXR), and if effusions were stable, to switch to apixaban. She remained stable and was discharged.

The health plan's determination is overturned.

The inpatient stay was medically necessary for this patient.
Her pulmonary embolism severity index (PESI) score was 113, class IV, high risk, with a 30d mortality of 4-11%. She fails one of the Hestia criteria (high risk of bleeding) so would be excluded from the group receiving outpatient care in these studies.
Additional reasons for admission include concern for pleural space hemorrhage given bloody thoracentesis from the day prior. Oncology suggested starting with a heparin drip due to this possibility and observing the patient, repeating the CXR after a day to ensure the effusions weren't growing, and then switching over to longer acting direct oral anticoagulants (DOACs).
Two of the most commonly used risk stratification systems would suggest she is not a good candidate for outpatient treatment. Additionally, there was concern expressed by her clinicians for developing pleural space hemorrhage while on anti-coagulation, necessitating close monitoring while treatment was initiated. Heparin was chosen given its rapid reversibility in case of bleeding, and this can only be provided in the inpatient setting, requiring frequent labs. 
Criteria provided that she met include presence of a chronic cardiopulmonary disease (COPD), bleeding before anti-coagulation (sanguineous thoracentesis the day before which raised the oncologist's concern for hemorrhage and led to the recommendation for a heparin drip and repeat CXR to ensure effusions weren't enlarging prior to starting a longer acting anti-coagulant).
Appeal type: Medical necessity
Decision: Upheld

The patient is a female who was at 9 weeks 5 days gestation who was admitted for vomiting. She was diagnosed with hyperemesis gravidarum. She had an abdominal ultrasound that showed sludge without evidence of acute cholecystitis. Vital signs were normal. She was provided intravenous hydration and medications for nausea. She improved and was tolerating oral intake. At issue is the medical necessity of the inpatient hospital stay. The health plan's determination of medical necessity is upheld in whole. The requested health service/treatment of inpatient hospital admission is not medically necessary for this patient.
The patient was admitted to the hospital secondary to vomiting at home with hyperemesis gravidarum. She was hemodynamically stable and vital signs were normal. She had no evidence of acute cholecystitis. She had no evidence of an acute abdominal injury or pathology that required inpatient level of care or surgery. She had no severe electrolyte abnormalities, severe vomiting, renal failure or neurological changes. The patient had not failed outpatient managements. She could have been treated at a lower level of care until she felt well. Therefore, inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a case of a patient with no major medical history, who presented to the emergency department, with complaints of aphasia. The patient's last known normal state was 19 hours prior; the patient woke up with aphasia, right upper and lower extremity weakness, worsening over time. The patient was not taking any medications at the time of the presentation. A rapid response was activated, and the patient was sent for a computed tomography (CT) scan of the brain with CT perfusion and angiogram. The patient's patient's brain MRI, which showed acute to subacute infarct in the posterior limb of the left internal capsule. The the health plan's determination of medical necessity is overturned in whole.
The requested health service treatment of inpatient medical stay is necessary for this patient.This patient presents to the hospital with typical signs and symptoms of acute stroke, with weakness in the right upper and lower extremity, facial droop, and dysarthria. The symptoms persisted and did not resolve immediately.This type of presentation is typically managed under inpatient status. A lower level of care was not appropriate.in this case.The patient's admission based on Milliman Care Guidelines (MCG) criteria for acute ischemic stroke, the patient satisfies the criteria, for hospitalization under the inpatient status.