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

Diagnosis: Cardiac Circulatory problems /chest pain 
Treatment: Inpatient hospital 
The insurer denied the inpatient hospital stay. 
The denial is upheld in whole.


This case involves a patient with a history of hypertension hyperlipidemia and transient ischemic attack (TIA), who presented to the hospital with chest and abdominal pain. The symptoms have been present for at least two days. 

No, the requested health service/treatment of inpatient hospital stay is not medically necessary for this patient. The presentation can be accomplished under a lower level of care.

The patient presents to the hospital with nonspecific chest pain, with some typical and atypical features. The patient's heart score is 4, which prompted further evaluation in the hospital to rule out an acute coronary syndrome. Serial cardiac enzymes were normal. Aortic dissection was ruled out. The abdominal discomfort subsided within 24 hours of admission. This type of presentation is typically managed in a lower level of care unit without the need for admission to the inpatient level of care. This is well supported in medical literature, and in line with standards of medical care. The peer-reviewed medical literature supports this approach.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Respiratory Failure

Treatment: Transfer to a long-term acute care hospital

The insurer denied the transfer to a long-term acute care hospital.

The denial was overturned.

This is a female patient with a history of hypertension, hypothyroidism and pre-diabetes.  The patient was Covid-19 positive and developed chronic respiratory failure with tracheal stenosis/tracheomalacia.  The patient also had a stage 4 sacral ulcer with wound care that required a wound vac.  Post-acute rehabilitation was necessary for tracheostomy/oxygen weaning, frequent suctioning, intravenous (IV) antibiotics, tube feeds, complex wound care, daily physician visits, and physical therapy (PT), occupational therapy and speech therapy.

Based on the review of the medical record and literature, it is considered clinical appropriate and medical necessary to transfer this patient to a long term acute care hospital (LTACH). This determination is made after taking under consideration the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. The patient has clinically complex medical conditions that will require long term acute care that is at a higher level than that of a skilled nursing facility.  The patient's long-term medical care needs, which include trach/oxygen weaning, frequent suctioning, intravenous (IV) antibiotics, tube feeds, complex wound care and daily physician visits are best provided in a long term acute care setting. As noted by Eskildsen, et al. "Modern LTAC emerged in the early 1980s as a setting for the weaning of ventilator-dependent patients. ......Although LTAC is mainly known for providing chronic ventilator weaning, the case mix is varied."  In addition, the patient will also require daily physical, occupational and speech therapy services.  The combination of the patient's long-term acute medical, nursing and rehabilitation needs support the clinical appropriateness and medical necessity of the requested long term acute care hospital (LTACH) for this particular case. 

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, transfer to a long term acute care hospital (LTACH) is medically necessary.  

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.  

The carrier's denial of coverage for transfer to a long-term acute care hospital (LTACH) should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Endocrine
Inpatient hospital

Diagnosis: fatigue
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a man on methadone with history of diabetes, hypertension, asthma, hepatitis C, and hypothyroidism who was admitted to the hospital. He was admitted for generalized fatigue for the past few days. He stated that he had recently run out of medication and not been taking his thyroid hormone supplements. He also reported falling onto his back. In addition, review of symptoms was positive for a cough and white-yellowish sputum. He denied fevers but did report chills. He also denied chest pain and shortness of breath. Vital signs showed blood pressure 163/98, heart rate 59, temperature 98.2 Fahrenheit, and respiratory rate 17. On physical examination, he was in no distress, heart was regular, breath sounds were normal, he was alert and oriented, and there was no cranial nerve deficit reported. Labs showed sodium 137, creatinine 1.5, calcium 9.4, potassium 4.0, white blood cell (WBC) 8.2, hemoglobin 11.1, and platelets 215. Chest x-ray showed possible small infiltrate. An electrocardiogram (EKG) showed sinus bradycardia. Thyroid stimulating hormone level was 100. The patient was admitted for symptomatic hypothyroidism. The plan of care included endocrine consultation, supplemental thyroid hormone, telemetry, monitor electrolytes, hypertension management, bronchodilators and continue other home medications. His methadone dose was not confirmed and he was given 20 milligrams (mg) of methadone during his hospital stay. He was discharged  with a plan for outpatient follow up.

The inpatient stay was not medically necessary. The reason is that the patient presented with evidence of symptomatic hypothyroidism but did not require intravenous (IV) levothyroxine, did not have evidence of hemodynamically significant bradycardia, myxedema coma, acute electrolyte abnormalities, or other acutely concerning abnormalities.
The patient was hemodynamically stable and could have been treated at a lower level of care with a similar regimen of supplemental thyroid hormone to treat symptomatic hypothyroidism. He had no evidence of sepsis, cardiac arrhythmia, coma, or other acutely concerning symptoms or signs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vertigo.

Treatment: inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is a male patient who was brought to the Emergency Department (ED) by ambulance from home. The patient had subjective complaints of vertigo that began spontaneously. The patient reported waking up at around 4:00 am to use the bathroom, and felt slightly dizzy but did not think anything of it. The patient woke up again at 6:45 am with severe vertigo and nausea. The Emergency Medical Services (EMS) reported that the patient vomited on their arrival. The patient admitted to having cold-like symptoms over the prior week, but had no further complaints. The patient reported having experienced vertigo many years before this current episode of vertigo. The patient denied fever, chills, chest pain, and shortness of breath, palpitations, headache, blurry vision, trauma, paresthesia, anesthesia, abdominal pain, and lethargy. 

The patient's physical examination revealed that his blood pressure was 129/84 and his heart rate was 62. The patient's temperature was 97.4. The patient's pupils were clear bilaterally, equal, round, and reactive to light. The patient had a normal cardiac rhythm and rate. The patient's National Institute of Health Stroke Score (NIHSS) was 0. The patient's cranial nerves 2 through 12 were intact. The patient underwent laboratory studies. There were no laboratory abnormalities. The patient's computed tomography (CT) scan of the head revealed no evidence of acute intracranial hemorrhage or territorial infarction. The patient's electrocardiogram (EKG) revealed normal sinus rhythm, and a normal EKG. The patient was treated with fluids and medications. The patient had intractable vertigo and was still dizzy. The patient was unable to ambulate without teetering over. With no clinical improvement in the ED, the patient was admitted for observation for the diagnosis of vertigo. 

Based on the review of the medical record and literature, the patient presented with vertigo. The patient's diagnostic workup was unremarkable with no clinical signs or symptoms suggestive of central vertigo that required inpatient admission. The patient did not receive any services that required an inpatient level of care. The patient could have been monitored in the ED, or at most, at the observation status prior to being discharged home with close follow-up in the outpatient setting. Thus, inpatient admission was not medically necessary for this patient. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

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

Diagnosis: Cellulitis

Treatment: an acute inpatient stay

The insurer denied coverage for an acute inpatient stay.

The denial is upheld.

This is a female patient with a benign past medical history who presented to the Emergency Department (ED) with complaints of left leg pain, swelling, and erythema. The patient's vital signs on ED presentation included: temperature 99.4 F, blood pressure 124/64, pulse 111, respiratory rate 22, and oxygen saturations 99% on room air. The patient's laboratory results included the following: white blood cell (WBC) 8.1, hemoglobin 13.8, hematocrit 41.1, creatinine 0.7, and glucose 99. The patient was started empirically on intravenous (IV) fluids and antibiotics for lower extremity infection. The patient's ultrasound duplex of the lower extremity was negative for deep vein thrombosis (DVT). The patient was initially admitted to the observation unit, but was eventually hospitalized. The patient's cultures remained negative. The patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue outpatient management on oral antibiotics. 

Based on the review of the medical record, the patient presented with bilateral leg cellulitis. The patient was treated on oral antibiotics as an outpatient prior to presenting to the hospital. Otherwise, the patient was afebrile, hemodynamically stable with unremarkable laboratory results including a normal WBC count. Documented failure of outpatient intervention by itself does not warrant automatic hospitalization. On exam, the patient was described as "comfortable", and did not have any evidence of a disseminated infection, and no surgical intervention was required. Based on these clinical findings, the patient did not meet criteria for acute inpatient hospitalization. As per literature review, inpatient admission was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

Based on the above, the medical necessity for the acute inpatient stay is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis

Treatment: a full hospital admission

The insurer denied coverage for a full hospital admission.

The denial is upheld.

This is a female patient with a history of osteoarthritis to her knees. The patient also had peripheral vascular disease. The patient was admitted to the hospital for an elective right total knee replacement. The patient's post-surgical course was non-complicated. The patient received a pain control regimen which was effective.

Based on the review of the medical record, the patient had a non-complicated, post-surgical course after her elective right total knee replacement. The operation was without problem with limited blood loss. The patient did not require blood transfusion and did not need a drain placed. The patient was able to tolerate oral pain medications, and there were no issues associated with her surgical wound. The patient's vital signs and laboratory tests were stable. The patient was able to participate in physical therapy (PT) and was ambulatory. There were no extenuating circumstances to substantiate this patient's inpatient admission and length of stay. Thus, based on a review of the Milliman Care Guidelines (MCG) for ambulatory surgery, inpatient admission was not medically necessary for this patient. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The medical necessity for a full hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Asthma.
Treatment:  Inpatient stay.
The insurer denied the inpatient stay.  The health plan's determination is upheld. 

The patient is a male child with medical history significant for frequent epistaxis, remote history of intermittent asthma, and family history significant for adult-onset asthma, who presented to the emergency department (ED) in the early morning with two-day history of worsening cough, tactile fever, congestion, and sore throat, and one-day history of difficulty breathing.  Vital signs included temperature 98.8, heart rate 118, respiratory rate 22, blood pressure 117/71, and 96% saturation in room air.  Examination was significant for moderate respiratory distress with nasal flaring, erythematous tympanic membranes with loss of landmarks, shotty anterior cervical lymphadenopathy, tachycardia, poor air entry bilaterally with subcostal/intercostal/suprasternal retractions and belly breathing, pallor, and non-focal neurologic exam.

The inpatient stay was not medically necessary.  This patient with remote history of intermittent asthma presented to the ED (after seeing his pediatrician the day before) with worsening cough and increased work of breathing.  He was initially poorly responsive to aggressive bronchodilator management in the ED including continuous albuterol.  However, he had no need for supplemental oxygen, with no evidence of impending respiratory failure or sepsis.  He was able to start weaning albuterol at the time of transfer to the pediatric floor.  Based on the documentation provided, he did not require acute inpatient admission and could have safely been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Gynecological
Inpatient Hospital

The patient is a female who presented to the emergency room (ER) and complained of constant cramping radiating to the left shoulder, pain rated 10/10. She also complained of nausea and vomiting. She appeared in mild distress with some abdominal tenderness without guarding or rebound tenderness. Her medical and surgical histories were unremarkable. Her hemoglobin was noted to have dropped 2 points over her time in the emergency department (ED) and her hemoglobin on was 8.5 Her initial vital signs in the ER showed tachycardia at 128, and hypotension with blood pressure of 92/66. Upon recheck later on the tachycardia had resolved and her blood pressure (BP) was essentially unchanged. Her coagulation studies were normal. A computed tomography (CT) and sonogram were suspicious for ruptured right ovarian cyst. She required intravenous (IV) analgesics in the ED. A progress note the next day noted her vital signs remained stable over 24 hours of strict observation and the patient had mild tenderness in the right abdomen. She had no rebound tenderness. Her hemoglobin was 7.7. The plan was to repeat complete blood count (CBC). A progress note the following day states the patient felt much better with stable vital signs, hemoglobin was 8.7. The plan was for discharge that day. The discharge summary states her pain was secondary to right corpus luteum cyst bleeding and her vital signs were stable throughout her stay. Her hemoglobin dropped from 10.5 to 7.7 during her stay but rebounded to 8.7. She was discharged home.

The health plan's determination is upheld.

No, the requested inpatient stay was not medically necessary for this patient. In this case, data confirms a large majority of women with ruptured ovarian cysts can be managed non-operatively, but some will require surgery as indicated by a large drop in hemoglobin or development of hemodynamic instability. This patient required monitoring of these parameters to help decide if she required admission for surgery. She otherwise did not require inpatient level of service; therefore, an inpatient level of care was not medically necessary. Monitoring this patient's vitals was safe and reasonable and could be carried out at a lower level of care status.

Per Milliman Care Guidelines (MCG) Health General Recovery Care: Obstetric and Gynecologic Disease General Recovery Guidelines (GRG) MG-OBD, inpatient admission is typically indicated for amniotic fluid or pulmonary embolism, suspected peritonitis or ectopic pregnancy requiring prolonged monitoring, fetal compromise, obstetric infection, ovarian hyperstimulation syndrome, pelvic infection, pregnant or postpartum state with severe complications or uterine bleeding with high-risk features. This patient was not pregnant, had no signs of infection and denied uterine bleeding. There was no documented embolism. Therefore, the MCG criteria for medical necessity were not fulfilled.

In summary, the patient did not require an inpatient level of care and could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

The patient has a past medical history of hypertension, osteoporosis, insomnia, anxiety, depression and memory loss who has personal care assistant (PCA) services 8 hours per day, 5 days per week and 9 hours per day, 2 days per week to total 60 hours per week. The patient had a noted deterioration of chronic medical conditions following a head injury after a fall and another fall recently. The patient's provider noted the patient had an increased need for help with personal hygiene, walking, locomotion and toilet use but the assessment tool did not note these changes. The patient does not have an informal caregiver. The patient does have unscheduled needs. The patient's provider has noted medical necessity for increased PCA service hours. At issue is the medical necessity of the increase in personal care assistant hours to 84 hours a week. 

The health plan's determination is overturned. The requested health service/treatment of increased personal care assistance hours from 56 hours per week to 84 hours per week is medically necessary for this patient. 

The patient had a fall with a head injury and with an increasing need for help with walking, transferring, toilet use. The patient's physician noted the patient with deteriorating chronic medical issues requiring more help with activities of daily living (ADL's) and instrumental activities of daily living (IADL's). The patient noted to have worsening coordination, gait deficit, decreased range of motion and dizziness. The patient has fallen multiple time with resultant hospitalizations. The office note reported the patient needed more help with walking, transferring, bathing, dressing, incontinence care, assistance with meal preparation, eating and help with managing medication. The provider noted the PCA services were needed 12 hours per day, 7 days per week to total 84 hours per week. The patient had another fall requiring hospitalization. There was a letter from the patient's advocate noting the patient was alone from 6 pm until 10 am. The patient has no informal caregiver and does have unscheduled personal care needs. There was an assessment tool performed, showing an increased need for help with activities of meal preparation, ordinary housework, managing finances, phone use, shopping, bathing and eating. There was no change in the need for help with activities of personal hygiene, dressing upper extremities (UE) / lower extremities (LE), walking, locomotion, transferring from toilet, toilet use and bed mobility compared to the previous assessment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting; Abdominal pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult male with a history of alcohol abuse, diabetes and depression. He presented to the hospital with vomiting and abdominal pain.

The patient's labs were notable for a white blood cell count 14,300, potassium 4.1, bicarbonate 19, and creatinine 3.5.  An abdominal ultrasound showed cholelithiasis without acute cholecystitis.  Pancreatic enzymes and liver function tests were normal.  Intravenous fluids and an alcohol withdrawal protocol were provided.  Nephrology was consulted.  The patient's diet was advanced successfully.  A renal ultrasound demonstrated no hydronephrosis with increased echogenicity.  The creatinine on follow-up was between 3.3-3.7.

The patient had vomiting and abdominal pain that was afebrile and hemodynamically stable.  There was no evidence of gastrointestinal obstruction, acute pancreatitis, acute cholecystitis, or ischemic bowel.  The diet was advanced successfully.  The abdominal ultrasound demonstrated only cholelithiasis without acute process.  There was no evidence of alcohol withdrawal.  Renal function remained stable during the hospitalization, and there was no documentation to support the presence of acute kidney injury.  The renal ultrasound demonstrated no hydronephrosis and showed cortical thinning consistent with chronic kidney disease.  Dialysis was not required.  The patient did not have hyperkalemia, uremia, severe acidosis, or volume overload.  Glycemic control was acceptable.  

In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cognitive impairment, chronic neck/low back pain and associated gait ataxia
Issue under review: Increase in PCA services

Determination:
The Increase in PCA services is not medically necessary.

The patient is an adult female with a history of cognitive impairment, chronic neck/low back pain and associated gait ataxia. For these reasons, she requires assistance with many of her activities of daily living (ADLs). An in home assessment of the patient's overall functionality and ability to perform ADLs was completed in fall of 2019 and indicated that the currently approved plan of 24 hours/week personal care assistance services is sufficient to meet the patient's current needs. There is no additional documentation indicating that the patient has sustained further functional decline since the date of this last assessment. For these reasons, the proposed treatment of an increase in personal care assistance services from 24 to 42 hours/week is not deemed medically necessary.