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

Diagnosis: Hypertension, Right Bundle Branch Block 
Treatment: Inpatient Admission 

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

This is a male patient with a history of rheumatic fever, hypertension, prostatitis. The patient presented to the Emergency Department (ED) with complaints of shortness of breath and an abnormal electrocardiogram (EKG). He was evaluated by cardiology. An EKG was performed that revealed normal sinus rhythm with a right bundle branch block. Troponin levels were drawn with negative results. A chest x-ray was performed that showed no acute cardiopulmonary disease. He was admitted to the hospital for further monitoring. An echocardiogram was done that revealed an ejection fraction of 65%, no regional wall motion abnormalities, wall thickness within normal limits, and mild tricuspid regurgitation. A stress test was done with normal results. He was consulted by Medicine service for hypertension; his blood pressure medication was adjusted. After a period of medical stability the patient was discharged home. 

The patient presented with shortness of breath and an abnormal EKG showing a right bundle branch block. The initial evaluation in the ER was unremarkable, including a non-diagnostic EKG and cardiac biomarkers. Inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted; however, inpatient admission criteria were not met. There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest. 

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

Diagnosis: Bronchiolitis

Treatment: Inpatient hospital admission 

The insurer is denied coverage for inpatient hospital admission.

The denial is upheld. 

This patient was a male child. Upon delivery, the patient required treatment with a ventilator for a couple of weeks, and remained hospitalized in the neonatal intensive care unit (NICU) for several weeks prior to discharge. The patient's family history was significant for asthma. This patient presented to the Emergency Department (ED) with history of being sick with nasal congestion for several days. The patient was prompted to the ED when he developed a barking cough, night prior to ED arrival. 

In the ED, the patient was noted to be in mild respiratory distress with evidence of increased work of breathing, including subcostal retractions, wheezing and stridor. The patient was treated with Decadron, racemic epinephrine and 2 doses of albuterol. Following this treatment, the patient's stridor improved but had persistent wheezing and tachypnea. So, the decision was made to admit the patient with a diagnosis of bronchiolitis for ongoing observation of his ability to safely tolerate feedings. There was no plan to continue to administer albuterol or IV fluids during the hospital admission. The patient arrived to the ED and was transferred to the Pediatric inpatient unit. After a period of observation on the Pediatric floor, the patient was noted to be breathing comfortably with no respiratory distress. The patient was found to be clinically stable and tolerating his feedings. Thus, the patient was discharged on the same day.  

Based on the review of the medical literature, the patient was treated appropriately in the ED for his barking cough, wheezing and stridor. After receiving his respiratory treatment in the ED, the patient was noted to have significant improvement in his respiratory status. The patient was admitted for his bronchiolitis. However, this patient's inpatient plan did not include the need for frequent respiratory treatments and/or intravenous hydration that required inpatient level of care. The plan was to observe the patient and make sure the patient was able to tolerate feedings. The patient was admitted for approximately several hours, and during this inpatient stay, the patient did not receive any treatment that could not have been safely provided at a less intensive level of care, such as observation. The patient was afebrile and responsive to ED treatment. The patient could have been discharged with a diagnosis of bronchiolitis after a period of observation with appropriate follow up with his pediatrician in 24 to 48 hours as outpatient. The inpatient admission was not medically necessary to treat this patient's medical condition.

The health plan acted reasonably with sound medical judgment, and 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

This is a patient with neck and back pain, with treatment including spinal manipulation, ultrasound and mechanical traction.  The patient has a treatment history with this provider for similar pain, with Visual Analog Scale (VAS) varying from 3-7/10 during first round of treatment dates, VAS of 8/10 during second round of treatment dates, and VAS ranging from 6-7/10 to 5/10 in a third round of treatment dates.  There was no significant change in symptoms or findings.  There was billing for CPT 99212 and re-examination.  At issue is the medical necessity of chiropractic care CPT 99212.
The health plan's determination is upheld
The requested services were not medically necessary.  The patient was seen for a number of episodes with the same chief complaints with no change of symptoms.  There was not a new condition, a significant change in symptoms, a need to re-assess for treatment response or a change of treatment plan.  The lack of objective clinical findings supporting ongoing clinical improvements did not establish medical necessity using the standards of care noted below, such as the American College of Occupational and Environmental Medicine (ACOEM) or Official Disability Guidelines (ODG), both well-recognized national practice guidelines.
 
Per the Guidelines for Chiropractic Quality Assurance and Practice Parameters, "Treatment/care be documented as having therapeutic necessity."  "A course of two weeks each of two different types of manual procedures (four weeks total), after which, in the absence of documented improvement, manual procedures are no longer indicated" (adequate trial of treatment/care).

Per the American College of Occupational and Environmental Medicine (ACOEM) Occupational Medicine Practice Guidelines,  Summary of recommendations for evaluating and managing neck and back complaints; physical manipulation for neck pain early in care only, ". . . with less than three months activity intolerance due to neck symptoms and/or neck-related arm symptoms potentially related to occupational injury or exposure. Observe and treat (without testing) for 4-6 weeks." 
Therefore, medical necessity is not established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Vascular dementia
Issue under review:  Personal care services

Determination:
The Personal care services are medically necessary.

This is an elderly female with a history of vascular dementia and gait ataxia.  For these reasons, she is dependent on assistance for completion of the majority of her activities of daily living (ADLs) including bed mobility, transfers, ambulation, meal preparation, feeding, bathing, toileting and clothing.  Furthermore, documentation from the patient's primary care physician indicates that due to the patient's frequent nocturia of approximately three to four times/night, she requires frequent nighttime assistance with bed mobility, transfers, ambulation and toileting.  The currently approved plan of personal care services is insufficient to meet the patient's needs.  Hence, the proposed treatment of an increase in personal care services is deemed medically necessary to offer improved assistance with completion of the patient's ADLs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Issue under review: Braces and periodic visits

Determination:
The Braces and periodic visits are medically necessary.

The patient is a teen-aged female. The request is for orthodontic benefits.The patient has her upper left first premolar in buccal crossbite. This means that tooth #12 is way too far towards her cheek and consequently will not mesh properly with the tooth below it. It will hit in a traumatic way, which could cause fracturing and/or loosening of both teeth over time, and possible tooth loss. For the health of her teeth, the patient needs this upper tooth aligned with the rest of her teeth so everything meshes together properly. Orthodontic treatment is the only way to fix this situation. The monthly periodic visits are to monitor the progress of the treatment.

Therefore, given the above, the Braces and monthly periodic dental visits are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Right renal colic
Issue under review:  Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult female.  She was admitted with right renal colic.  She had also presented to the ER the prior day.  

The patient's vitals were 36.7-181/79-96-32.  The WBC (white blood cell) count was 7510.  The creatinine was 0.6.  CT imaging demonstrated a 2 mm right distal ureteral calculus with hydronephrosis.  A pelvic ultrasound was also performed.  IV pain medications, nausea medications, and IVF were administered.   

The following day, she was clinically improved and discharged home.  She was afebrile and hemodynamically stable throughout the stay.

An acute inpatient level of care was not medically necessary.  The patient's care could have been provided at a lower level of care.  She was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis.  Following admission, there were no unstable vital signs reported.  She did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery.  She did not have bilateral obstruction, acute renal failure, severe vomiting.  Pain control, IV antibiotics and IVF followed by stent placement in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Wheezing, cough, fever
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is a female infant with no significant medical history but family history of asthma. She presented to the ED with four-day history of cold symptoms with fever, two-day history of cough and same-day history of difficulty breathing associated with wheezing and decreased oral intake. She was seen in the ED two days prior and discharged home with supportive care, and was seen by the pediatrician the next day. 

The patient's vital signs included temperature 37.1, heart rate 119, and respiratory rate 24 with 100% saturation in room air. Examination was significant for mild to moderate respiratory distress, nasal congestion, moist mucous membranes, subcostal and intercostal retractions with good air entry bilaterally, expiratory wheezing, and non-focal neurologic exam. She was treated with normal saline lavage with suction, and testing for RSV (respiratory syncytial virus) and influenza was ordered. 

Because of need for deep suctioning and persistent increased work of breathing, the patient was admitted for further care. Testing was negative for RSV and influenza. Admission orders included normal saline nebs every three hours as needed followed by Yankauer suction, pulse oximetry with supplemental oxygen as needed, anti-pyretics, and regular diet for age. 

Following admission, the patient was noted to be intermittently tachypneic with use of accessory muscles. She had rhonchi and wheezing on exam, so she was given a trial of albuterol with notable improvement. She was started on albuterol every two hours, spacing to every three hours as tolerated. By the next day, she was able to tolerate albuterol every four hours. Her appetite and intake improved, and she maintained good urine output. She was deemed stable for discharge later that day with instructions to continue albuterol for two more days routinely.

This young child with unremarkable personal medical history and family history of asthma presented to the ED with signs and symptoms consistent with either bronchiolitis or viral respiratory illness with reactive airway disease. She required deep suctioning and responded well to treatments with albuterol. She remained hemodynamically stable with no need for supplemental oxygen, no signs of impending respiratory failure, no significant or persistent dehydration. While it was reasonable to monitor her in the hospital for frequent breathing treatments, she did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Benign paroxysmal positional vertigo
Treatment: Inpatient admission

The proposed Inpatient admission was not medically necessary. Inpatient level of care was neither indicated nor provided.

The determination of level of care is 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. It is highlighted in the orders for care. 

In this case, the patient's symptoms were atypical and unlikely to be representative of acute coronary syndrome (ACS), malignant arrhythmias or serious cardiac abnormalities. The physical exam and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. CXR was normal. Echocardiogram showed no wall motion abnormality (WMA).  The physicians' treatment did not reflect any serious concern about the patient's cardiac condition.  Orders did not include medical therapy for ACS, such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV NTG (nitroglycerin).  Aggressive measures were not required for his orthostasis.  

The letter of appeal was carefully, considered but it offered no evidence to support an inpatient level of care. The statement that, "All of this could not be done in an outpatient setting," is not consistent with orders and treatment. 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. There was no complex care that required inpatient care.  While there was always a potential for the adverse events listed, one did not happen, and no actual treatment was added.

The Milliman criteria requirements were not fulfilled for the Neurology or Dizziness sections, for the reasons listed above. Since all of the testing and therapy that were provided would have been appropriate, safe and guidelines-consistent in a lower level of care, then the 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: Coughing and wheezing
Issue under review: Inpatient admission

Determination: The inpatient admission was not medically necessary.

Asthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production. Gas exchange abnormalities are due to ventilation/perfusion mismatch, as a result of atelectasis and airway over-distention. Status asthmaticus is defined as "severe asthma that fails to respond to inhaled beta-agonists, oral or intravenous steroids, and requires admission to the hospital for treatment." (1) Unfortunately, asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. "Despite advances in asthma management, acute exacerbations continue to be a major problem in patients our review findings support the importance of controlling persistent asthma early episodic intervention appeared to be crucial in preventing severe attacks and future exacerbations." (2)
 
In the ED, primary management strategies include correction of hypoxia, rapid improvement of airflow obstruction, and prevention of progression. This is achieved with supplemental oxygen, bronchodilators, and steroids. Fluid hydration may also be necessary. For patients with moderate to severe exacerbations that do not respond to such intensive therapy in the ED, admission is necessary.

This female preteen with history of asthma presented to the ED with wheezing and respiratory distress refractory to bronchodilator treatments at home. She improved somewhat with management in the ED, but continued to have wheezing and increased work of breathing. While it was reasonable and medically necessary to continue monitoring her in the hospital with breathing treatments and IV fluids, she did not require acute inpatient admission. She was hemodynamically stable, with no oxygen requirement, no evidence of sepsis, no evidence of impending respiratory failure, and she was responding to treatment. She could have been safely and effectively managed at a lower level of care, such as observation.
Appeal type: Medical necessity
Decision: Upheld

Primary Diagnosis:  Respiratory System / Breathing Problem
Primary Treatment:  Inpatient Hospital 

The patient with a history of chronic obstructive pulmonary disease (COPD), asthma, tobacco abuse, cocaine abuse, coronary artery disease (CAD), gastritis and obesity. The patient  presented to the emergency room with shortness of breath, chest tightness, and cough after smoking a lot of cigarettes and using cocaine at a family function.  Upon admission, the patient was treated with intravenous corticosteroids, intravenous antibiotics, nebulizer treatments, inhalers, and oral medications.  The patient improved considerably over the next 24 hours and was discharged. The health plan's determination of medical necessity is upheld.
No, the requested health service/treatment of inpatient stay was not medically necessary for this patient.
Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary.  Upon presentation, there was no objective evidence on physical examination, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints.  There was no hypoxia, acidosis, evidence of sepsis, change in mental status, evidence of acute coronary syndrome or heart failure, or other significant metabolic disarray.  There was no evidence that she failed an appropriately aggressive outpatient treatment program.  Likewise, there is no evidence that her status did not improve appropriately in a lower level of care.  Therefore, based on the standard of care and the peer reviewed literature the inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

This patient presented with chest pain and a history of diabetes mellitus and hypertension.  Utilizing the HEART (History, ECG, Age, Risk factors, initial Troponin) score, she was considered low risk. (Reference 1)  Utilizing the TIMI (thrombolysis in myocardial infarction) risk score, she also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (Reference 2) 

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (Reference 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: Overturned

Diagnosis: Weakness in the legs
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient presented with acute weakness in the legs, which warrants a complete neurological workup, including imaging studies and consultation with neurology and neurosurgery. In this case, the patient had psychiatric issues that caused her to have weakness in the legs, which was nonphysiologic, but admission to the hospital and urgent evaluation was appropriate, as this patient could have had a serious pathology or cause for the weakness that required additional workup. This would not be appropriate to be performed in a lower level of care. Therefore, inpatient admission for this date is considered medically necessary