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

Diagnosis:  Syncope
Issue under review:  Inpatient admission

Determination:
The Inpatient admission was medically necessary.

This patient presented with loss of consciousness and seizure activity.  Several possible etiologies of loss of consciousness required work up.  Neurology and cardiac work up was performed appropriately.  Ultimately, the patient likely was volume depleted.  During work up, the patient was noted to have a depleted pacemaker battery in addition to right ventricular pacemaker lead dysfunction.  Battery change and lead revision were successfully performed, and the patient was discharged without complication.  Based on current guidelines, this patient would have a high risk of morbidity and mortality without admission to the hospital for additional testing (Reference 1, 2).  

Guidelines clearly state that when the etiology of syncope is unclear, admission to the hospital for further testing is appropriate.  In conclusion, it was appropriate to manage this patient at a higher level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
While hospitalization was indicated, the patient's care did not require an acute inpatient level of care.  The patient was afebrile and clinically stable.  He was on clear diet.  The use of pain medications and IV antibiotics, as well as JP and Foley care, can be safely and appropriately be administered at a lower level of care.  With an uncomplicated post-op stay of less than 48 hours, an acute inpatient level of care was not required because care could have been provided at a lower level of care.  A benefit of laparoscopic surgery is a quicker recuperation than open surgery.
Appeal type: Medical necessity
Decision: Overturned

The patient had a past medical history significant for hypertension, recurrent urinary tract infections, and breast cancer, in remission, who presented to the emergency department with complaints of rectal bleeding.
The patient started to have watery bowel movements that were brownish in color, and then the patient noticed recurrent episodes of bright red blood. 
The health plan's determination of medical necessity, is overturned in whole. The patient had ischemic colitis.  The care includes the administration of IV fluids, bowel rest, and antibiotics. In addition, patient needed close monitoring for signs of anemia as well as possible abdominal complications. The severity of the patient's condition and the complexity of the services provided are medically necessary for the inpatient level of care. The inpatient hospital admission was medically necessary for this patient at the inpatient level of care .
Appeal type: Medical necessity
Decision: Upheld

The patient is a previously healthy male who presented to the emergency department (ED) with a history of progressively worsening abdominal pain and diarrhea of 3-weeks duration. The patient underwent laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. The operative note describes an acute, non-perforated, appendicitis. He was provided IV fluid and perioperative antibiotics. The vital signs remained normal following surgery. He tolerated a diet and was discharged from the hospital. The health plan's determination is upheld.

The submitted clinical documentation does not support the need for inpatient admission for this patient. The patient required urgent surgical intervention for acute appendicitis, however, a lower level of care would have satisfactorily provided the care provided and would have been consistent with the accepted standard of medical care. There was no documentation of hemodynamic instability, intra- or peri-operative complications, severe pain, or unstable comorbidities. The patient tolerated oral hydration, diet and medication. Pain was well controlled. The records do not document hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications of the procedure that required inpatient care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Abdominal pain and dysuria
Treatment:  Inpatient admission
The inpatient admission was medically necessary.
A patient with uncomplicated pyelonephritis can be safely treated as an outpatient with oral antibiotics (1).  This patient does not meet the definition of "uncomplicated" because he presented with what can be a complication of pyelonephritis (hydronephrosis), the presence of which by itself as a new finding would warrant admission and evaluation to prevent loss of renal function (this is standard of care).  Even without these findings, the high WBC count and high lactate were worrisome (signs that the patient could go into sepsis/severe sepsis) and could be grounds for admission.  Thus, the admission is supported by Infectious Disease Society of American (IDSA) guidelines as well as standard of care.  Failure to admit such a patient could result in complications of pyelonephritis (abscess), loss of function (renal failure), sepsis, or death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out Acute Coronary Syndrome
 
Treatment: Inpatient Hospitalization

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

The patient was a female with a past medical history notable for diabetes mellitus, hypertension, hyperlipidemia, COPD, asthma, smoking, and depression. She presented to the emergency room (ER) with complaints of left-sided chest pain that radiated to her left arm, and was associated with nausea. Vital signs were stable. She had been admitted several days prior to this admission with similar complaints. She was admitted to rule out acute coronary syndrome. Cardiac enzymes remained negative. Her pain was felt to be musculoskeletal in nature, and she was discharged home.
The patient presented with chest pain, however the initial evaluation in the ER was unremarkable, including negative cardiac troponin and a non-diagnostic EKG. Inpatient admission was not medically necessary for this patient. In the absence of elevated cardiac biomarkers and a diagnostic electrocardiogram, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing prior to discharge. Further evaluation was warranted, however inpatient admission criteria was not met.  Medical criteria were not met for any other additional extenuating circumstance. There were no other high-risk co-morbidities. The hospital should not be reimbursed at the acute inpatient rate, but rather at the observational rate. 


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

Diagnosis: Altered mental status

Treatment: IV fluids, echocardiogram and EEG

The insurer has denied inpatient admission. That denial was upheld.

This female patient was brought in by ambulance to the ER due to shaking and altered mental status. Family noted the patient had a shaking episode for about 10 minutes; following this, she was unresponsive for about 20 minutes. Her medical history of coronary artery disease, hypertension, hyperlipidemia and diabetes mellitus type 2. She was started on IV fluids and plan included echocardiogram and EEG. EEG report indicated normal routine EEG study. She discharged.
This patient reported to the ER after a ten-minute episode of shaking and unresponsiveness. There was no report of tongue biting or urinary or bowel incontinence at that time. In the ER, the patient had a blood pressure 165/89 with a pulse 91, respirations 18, oxygen saturation 99% and temperature 37.0 C. Her labs were unremarkable. Her EKG was normal; chest x-ray and head CT showed no abnormalities. According to medical literature, an inpatient admission is indicated if there is evidence of hemodynamic instability, status epilepticus or repetitive seizures not controlled with emergent treatment, brain disorder that requires monitoring or intervention, etiology that requires monitoring or intervention available only at the inpatient level care, cardiac arrhythmia of immediate concern, altered mental status is severe persistent, new focal neurological deficit, metabolic disorder that persist despite observational care treatment, recurrent seizure, outpatient anti-seizure regimen that cannot be established, cerebral bleeding, hydrocephalus or vasospasm monitoring or increased intracranial pressure cerebral edema monitoring. There is no evidence that any of these conditions were present for this patient; thus, the patient's condition was appropriate for level of observational care rather than inpatient level of care.
Based on the above, the medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever and cough
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

Pneumonia occurs as a result of inflammation of lung tissue from either infectious or non-infectious causes. Infectious causes include bacteria, viruses, and fungi. Non-infectious causes include aspiration, hypersensitivity reactions, and drug- or radiation-induced pneumonitis. Streptococcal pneumoniae is the most common bacterial pathogen of infants and young children, while Mycoplasma pneumoniae and Chlamydophila pneumoniae are the most common bacterial pathogens of children and adolescents. Other bacterial agents include Streptococcus pyogenes and Staphylococcus aureus. Viral pathogens include respiratory syncytial virus (RSV) and influenza, as well as rhinovirus, human metapneumovirus, parainfluenza, and adenovirus. Bacterial pneumonia typically occurs when organisms from the respiratory tract colonize the trachea and then gain access to the lungs, although hematogenous spread is also possible. Different bacterial pathogens invade according to their own specific pathogenic processes. Viral pneumonia occurs from viral spread along the airways accompanied by direct injury to the tissues with subsequent airway obstruction. Clinically, pneumonia is typically preceded by upper respiratory tract infection symptoms, including cough and runny nose. The type and degree of symptoms of lower respiratory tract infection depend upon the organisms and stage of illness. Tachypnea, fever, cough, and chest pain may all be present. Physical examination findings may include decreased breath sounds, crackles, tachypnea, and shortness of breath. Infiltrate on chest x-ray is supportive of the diagnosis, and may be accompanied by effusion. There may be laboratory indicators of infection, including leukocytosis and elevated inflammatory markers. Treatment is based on the suspected cause. Hospitalization may be warranted in the very young, patients with concurrent serious chronic medical conditions, moderate to severe respiratory distress, need for supplemental oxygen, dehydration, inadequate response to outpatient therapy, and complications such as empyema or abscess.

This girl was stable in room air, able to tolerate food and fluids by mouth, with no respiratory distress and no evidence of sepsis. While it was not unreasonable to monitor her for possible decompensation, she did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.
Appeal type: Medical necessity
Decision: Upheld

The patient is morbidly obese with hypertension, hyperlipemia and coronary artery disease. The patient presented to the emergency department after a stress echocardiogram, done for a complaint of three days of intermittent chest pain, which showed evidence of ischemia. The blood pressure was 145/86 mmHg, with a heart rate of 95 beats/minute. Room air oxygen saturation was 96%. The cardiac exam was unremarkable.The serum troponin level was normal. There were no acute changes on electrocardiogram. Coronary angiography was performed and showed an 80% stenosis in the left anterior descending coronary artery that was treated with a stent. The procedure was uncomplicated. The patient was discharged home the following day. The requested health service/treatment of inpatient hospital admission was not medically necessary for this patient.
 While some period of observation immediately following percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. This patient did not have a myocardial infarction and, while the patient's symptoms and angiographic findings were consistent with unstable angina, patient was hemodynamically stable, and the electrocardiogram was normal. The procedure was uncomplicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient was overtly symptomatic at home with severe headache and hypertension, but her symptoms resolved when she was in the hospital. Ruptured aneurysm or intracranial hemorrhage was ruled out. The patient's vital signs were stable, and there was no ongoing neurological dysfunction or neurological deficits noted. Considering the patient's clinical stability, there was no need for inpatient acute care, and the patient could have been managed at a lower level of care, such as observation state. 

The patient's clinical and neurological status improved in the hospital, and acute inpatient care was not needed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sepsis
Treatment: Inpatient stay 

Summary:
This is a woman with a past medical history pertinent for ulcerative colitis and sclerosing cholangitis who presented to the ER for further eval/management of potential sepsis. She was otherwise asymptomatic and intake vitals were afebrile, hemodynamically stable. There was no evidence of profound hypotension, tachycardia or hypoxemia. Labs were notable for elevated WBC, but no other findings consistent with end organ damage were noted. Medical records indicate that the patient was admitted solely for observation/monitoring and treated with an empiric course of IV antibiotics. She improved with the prescribed therapies with normalization of her WBC. She was subsequently discharged home in stable condition. 

There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the 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: Dyspnea
 
Treatment: Inpatient admission, medication, oxygen therapy, monitoring

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

The patient is a male who was admitted to the hospital with complaint of Dyspnea.  The patient had been recently discharged from the hospital with Azithromycin, steroids and bronchodilators, but was not compliant with his medications. Vital signs at presentation were temperature 99.1 F, heart rate 135, respiratory rate 45, and blood pressure 125/105.   Oxygen saturations were 92 %. Arterial blood gas (ABG) was PH 7.388, PCO2 44, PaO2 73, and HCO3 25. White blood cell count was 14.2 K and cardiac enzymes were negative.  Chest x-ray was within normal limits.  EKG showed Sinus Tachycardia with no acute changes.  Flu and Respiratory Syncytial Virus (RSV) testing was negative.  The patient was treated with intravenous (IV) Steroids, and Bronchodilators.  The patient was placed on bilevel positive airway pressure (BiPAP). He improved with treatment in the Emergency Department (ED) and was taken off BiPAP but later needed to be placed back on BiPAP as he became tachypneic again. The History & Physical note from later that day stated patient was in no acute distress.  There was no use of accessory muscles noted.  Mild scattered wheezing was noted with some decreased air entry bilaterally. The patient was continued on steroids, bronchodilator treatment.

Based on the patient's presentation and subsequent course it appears this patient did not require acute hospitalization.  He could have been placed on Observation status while diagnostic testing and treatment were initiated.  The patient improved after treatment in the ED.  He was afebrile and hemodynamically stable.  There was no evidence of Pneumonia.  The patient remained stable overnight and was discharged home on oral steroids and other maintenance inhalers.  

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

At the time of service the patient had a history of recurrent viral bronchiolitis that required two prior admissions, one at the age of 4 weeks that lead to intubation and Pediatric Intensive Care Unit (PICU) monitoring.  5 days prior the patient presented to the ED with cough and wheeze without fever.  A chest x-ray (CXR) had questionable left retrocardiac infiltrate that was later officially read as no consolidations seen.  Patient was given a dose of Amoxicillin and sent home with a prescription for 4 days of Orapred and 10 days of Amoxicillin, Albuterol with spacer and Ibuprofen.  The following day patient returned to the ED as the mother was unable to fill the prescriptions.  Patient was well appearing with expiratory wheezing and diffuse crackles heard on exam.  The patient was given amoxicillin, albuterol and Decadron and sent home.
Patient presented this time with a 2 day history of wheezing, increased work of breathing, nonproductive cough and nasal congestion in the setting of a 9 day history of a respiratory illness.  The mother reported compliance with the medications.  The patient was on day 6 of Amoxicillin and status/post 4 days of prednisolone.  2 days prior to presentation the mother noticed the patient started to have audible wheezing with belly breathing and head bobbing.  Mother was giving 2-3 puffs of Albuterol with the spacer every 4 hours with little relief.  The mother denied any fevers, lethargy, vomiting or diarrhea.  The patient had decreased solid intake but normal by mouth (PO) liquid intake.  In the ED the patient was noted to be afebrile and well appearing on exam with mild intercostal retractions and expiratory wheezing.  Oxygen saturations were 99-100% on room air.  Patient was given Combivent x 1 and Decadron with resolution of wheezing and retractions.  The patient was given another Combivent x 1 and admitted to the floor.  No labs were performed in the ED.On the floor the patient was started on Albuterol every 3 hours. Amoxicillin was discontinued due to a lack of findings on CXR.  A consult was placed to pulmonology who recommended switching to a nebulizer for albuterol, starting Pulmicort and restarting Zantac for gastroesophageal reflux disease (GERD).  Patient was discharged on Albuterol nebulizers, Pulmicort, Zantac syrup, and Prednisolone.  The inpatient stay was not medically necessary, and the HP determination is upheld in whole.  Patient did not have symptoms that were severe or persistent after observation care treatment in the ED, nor did he have an inability to maintain oral hydration or lethargy.  After treatment with Combivent x 1 and Decadron patient showed improvement.  Admission exam did not document hypoxia or respiratory distress.  There was no mention of respiratory distress after admission.  Patient did not require any supplemental oxygen or increased intensity of services while admitted.  With  demonstrated improved clinical status after ED therapy, an inpatient admission would not be medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Preterm labor 

Treatment: Inpatient admission 

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

The patient is a female who presented to the ED at 33.5 weeks gestation with a chief complaint of abdominal pain. The patient was admitted, hydrated, monitored and received magnesium sulfate and Celestone. There was no documentation of cervical changes. She was discharged home. 
Preterm labor is an indication for admission and tocolysis. Preterm labor is defined as uterine contractions with cervical changes. Did this patient have preterm labor? 

During this admission, there was no documentation of cervical changes (cervical shortening). Neither the patient nor the fetus was in any jeopardy. There was no bleeding, and vital signs were stable. Fetal heart rate was reassuring. There was no evidence of ruptured membranes. 

Milliman Care Guidelines (MCG) lists the following clinical indication for antepartum admission:

(a)	Condition requiring premature delivery
(b)	Fetal distress or demise
(c)	Preterm labor and positive fetal fibronectin [fFN]
(d)	Significant maternal disease, infection or comorbidity as cause
(e)	Significant vaginal bleeding or any vaginal bleeding with known placenta previa, vasa previa or placenta accrete
(f)	Continued fetal monitoring
(g)	Tocolytic therapy that requires inpatient care
(h)	Complications of tocolytic treatment

This patient was stable and did not have any of the above. The management that this patient received could have been easily done in a less acute setting: Once the provider ascertained that there was no evidence of active labor, the patient could have been sent home. This is in accordance with standard of care and MCG.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospital services at the acute level of care from were not medically necessary for this patient. 

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who developed a recurrent ventral incisional hernia. She presented to the emergency department (ED). Vital signs were normal at the time of ED presentation. The examination  identified periumbilical tenderness and a reducible 1.5-centimeter (cm)ventral hernia. The patient underwent surgery.  The health plan's determination is upheld.
The operation and post surgical recovery period  was uncomplicated. The records support that inpatient care and treatment was not medically necessary. This patient required provision of parenteral analgesic as is documented in the medical record. However, the care and treatment provided, including the provision of IV fluid, pain medications, and antiemetics, as well as regular clinical assessment and follow up assessment, could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of hypertension, diabetes, and hyperlipidemia who came to the emergency department (ED) with complaints of hoarseness, tightness in throat, and odynophagia.  The patient switched from losartan to enalapril the day prior and had experienced upper respiratory infection (URI) symptoms for the prior week.  No lip or tongue swelling was noted, and there was no dyspnea or stridor.  He was seen by ear, nose, and throat (ENT) in the emergency department (ED) who performed fiberoptic laryngoscopy that showed mildly edematous right arytenoid and mild effacement of the right piriform sinus.  ENT recommended he be admitted to the Intensive Care Unit (ICU) for observation.

The health plan's determination is overturned.  The inpatient admission was indicated.  Although the patient improved rapidly, he presented with a potential acute airway obstruction with high risk of acute respiratory failure.  The patient had a number of high-risk features including voice change and evidence of laryngeal edema on endoscopy.  The patient's age also increased risk of needing intubation.  Given these features which increased risk of airway compromise and requiring intubation, an inpatient admission was needed for close monitoring.