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

Diagnosis: Asthma exacerbation
 
Treatment: Inpatient admission, monitoring, continuous positive airway pressure

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

The patient is a male with a history of diabetes mellitus, asthma, atrial fibrillation, morbid obesity, and obstructive sleep apnea. He presented to the Emergency Department (ED) with complaints of exertional dyspnea, sore throat, cough and runny nose for the past few days.  The patient denied fever, chills, or chest pain. He was noted to be non-compliant with his asthma medications. Vital signs in the ED were: temperature 98.2 F, respiratory rate 22, blood pressure 158/112, and heart rate 94.  Oxygen saturation was 95% on room air. The patient was in no acute distress and he was speaking in full sentences.  Lungs were clear to auscultation. He was alert and oriented x3. The patient's oxygen saturations decreased to 90-91% on ambulation. Rapid respiratory syncytial virus (RVP) was negative.  Arterial blood gas (ABG) was 7.39/46/72/27 94%.  Electrolytes were within normal limits, WBC count was 6.5K, and hemoglobin was 12.1. Chest x-ray showed no acute infiltrates. He was admitted for asthma exacerbation and was maintained on continuous positive airway pressure (CPAP) for obstructive sleep apnea.

This patient did not need acute hospitalization.  He could have been placed on observation status while diagnostic testing and treatment were initiated.  The patient remained stable after admission.  He was afebrile and hemodynamically stable.  He was tolerating oral intake.  There was no leukocytosis or pneumonia on chest x-ray.  The patient was stable to be discharged on oral medications after initial evaluation and treatment in the ED, with ongoing follow-up in an outpatient setting.  

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: Vaginal bleeding
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

In review of the medical record, the patient presented 11 days post-op from having had an anterior/posterior repair and a transvaginal tape surgery.  She had been doing well, but she began having some increased bleeding and discomfort.  She went to the ED.  She was evaluated and had normal blood pressure, mild tachycardia.  An EKG (electrocardiogram) was normal sinus tachycardia.  She was afebrile.  Her blood level was normal.  She had a GYN (gynecology) consult.  She was found to have a dehisced suture with some hematoma and bleeding.  This was evacuated and her vagina was packed.  She was admitted and had serial pad counts to assess bleeding, serial vital signs, and serial blood levels.  Her hemoglobin did drop to 10.8.  Her vitals remained stable.  The next day, the vaginal packing was removed and she had no further bleeding.  She was discharged home with outpatient follow up.  

The care provided did not require an acute inpatient level of care.  The patient did not require blood, telemetry, or other interventions that would necessitate inpatient care.  The same outcome could have been provided and achieved within the Emergency Department.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebrovascular accident, right knee arthroplasty
 
Treatment: Skilled Nursing Facility admission, therapy, monitoring

The insurer denied the continued stay in a skilled nursing facility. The denial was upheld.

This is a male with multiple medical problems including cerebrovascular accident (CVA) with left hemiparesis, hypertension, depression and anxiety.  He recently underwent a right total knee arthroplasty and was then was admitted to an extended care facility where he received physical and occupational therapy.  

The patient has remained essentially at the maximal assistance level for much of his functional mobility.  According to the physical therapy discharge summary, the patient required total assistance for transfer activities and remained non-ambulatory.  According to the physical therapist, "Maximal Status Achieved" and he was discharged from physical therapy.  The occupational therapy note indicated the patient continued to require moderate assistance for lower body dressing and bathing.  Short term functional goals had also not been met.     

The patient had been scheduled for discharge home with increased home care services.  The home care services were reportedly denied by his insurer.  However, the patient was no longer clinically appropriate for continued stay in a skilled nursing facility; continued treatment could have been provided at a lower level.  

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, continued stay in a skilled nursing facility was not medically necessary.  

The carrier's denial of coverage for the continued stay in a skilled nursing facility is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with asthma/chronic obstructive pulmonary disease (COPD), osteoarthritis (OA), and uterine cancer who presented with 4 days of cough and dyspnea, chest tightness, and wheeze. With more severe coughing fits, she had vomiting. She had occasional white sputum. She saw some blood tinged nasal secretions but no hemoptysis. A chest x-ray (CXR) found minimal peri-bronchial thickening with no focal infiltrate.
She was diagnosed with an asthma/COPD exacerbation. She had improved in the ED with nebulized bronchodilators and was started on intravenous (IV) steroids and levofloxcin. By the next day (6/8), she was improving, and her lung exam was described as clear. She remained afebrile, HR 89, peripheral capillary oxygen saturation (SpO2) 96%. Her symptoms seemed much better by the next day, and she was discharged on the day following. Treatments were continued. At issue is the medical necessity of an inpatient stay.
The health plan's determination is upheld.
The patient presented with dyspnea, cough, and wheeze. It appeared she did improve during her ED stay and according to the notes, had significantly improved symptoms by the next day. Her lung exam was wheezy on presentation to the ED but had cleared by the second day.
An inpatient admission was not medically necessary. She did not have severe symptoms, significant gas exchange abnormality, respiratory distress, encephalopathy, hemodynamic instability, or other organ dysfunction. Her BAP-65 score and DECAF scores suggest a low risk of death or need for intubation. Since she was at low risk for mortality or significant deterioration/intensive respiratory support, she did not need the close observation/monitoring provided by inpatient admission.
Appeal type: Medical necessity
Decision: Overturned in Part

The patient arrived at the emergency department (ED) via Emergency Medical Services  with complaint of abdominal pain, nausea and vomiting of 5 days duration. Her past medical history included prior gastric bypass, cholecystectomy, hernia repair, and a diagnostic laparoscopy for small bowel obstruction.The health plan's determination is overturned in part. The inpatient hospital stay was medically necessary. The records support that inpatient admission was medically necessary and consistent with standards of care for 4 days. The records do not support the need for continued inpatient admission beyond 4 days. This patient presented with abdominal pain, nausea and vomiting. The initial evaluation identified epigastric tenderness, a leukocytosis, and an abnormal CT scan consistent with acute pancolitis. The patient was started on IV antibiotics (Cipro and Flagyl). The patient  required IV fluid and IV antibiotics, imaging with CT scan and IV analgesia. This care and treatment spanned a period of 2 days and was most appropriately performed with an inpatient designation. Colitis as indicted by CT scan imaging carries the potential for clinical deterioration and was appropriately monitored in the inpatient setting for 4 days. Then on the 4th day, the patient had demonstrated clinical improvement such that the patient could have reasonably been discharged from the inpatient setting with plans for a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Severe right foot ischemia
Treatment:  Inpatient admission 

The patient is a male.  This patient presented with severe right foot ischemia.  His symptoms had begun roughly one month prior to this date.  At the time of his evaluation, he had severe rest pain as well as physical finding of a pre-gangrenous foot.  

The patient was admitted and underwent angiography.  The procedure consisted of endovascular therapy of his native system and included balloon angioplasty of the superficial femoral artery, popliteal artery, and the anterior tibial artery.  However, the treatment was considered only a temporary solution because of the patient's extensive vascular disease.  He was advised that he would need a bypass operation soon, or he would be at high risk for amputation.  He underwent medical and cardiac clearance, during which time he was maintained on intravenous heparin and intravenous pain medication.  

Upon undergoing cardiac clearance and being found to be at intermediate risk for surgery, the patient underwent revision of the old femoral distal bypass, as well as thrombectomy of the right anterior tibial and dorsalis pedis artery.  After this procedure, the patient continued to have poor circulation to the foot with only a poor quality distal Doppler signal.  Therefore, he was taken back to the operating room, where he underwent revision of the bypass.  Following this the patient's circulation was better with a palpable graft pulse and excellent distal flow.  

The patient required acute hospitalization for the entire time under review.  His admission was medically necessary, because he presented with subacute limb threat.  The procedure performed is sometimes an elective outpatient procedure. However, that depiction is incorrect for this particular patient, because he presented with severe foot ischemia and because his procedure was considered only a temporary fix.  In such instances, continued inpatient hospital stay is necessary because of the need for intravenous anticoagulation and preparation for an alternate means of revascularization.  Patients in this condition cannot be safely discharged, because they would be at high risk for amputation.  In fact, this particular patient was appropriately urged to stay in the hospital despite the fact that he expressed a wish to leave against medical advice.

The patient underwent a medically necessary preoperative workup, and he then underwent open surgical revascularization.  He had to go undergo open revision of this operation.  These medical events required continued inpatient stay.  He was discharged when it was determined that his bypass was working well with good foot perfusion.

Because of the high risk of loss of foot perfusion, the patient could not have been safely discharged at any point during the dates of service under review.
Appeal type: Medical necessity
Decision: Overturned

The patient is a male with asthma who presented to the emergency department (ED) with the acute onset of cough, wheeze, and shortness of breath. Symptoms did not improve with home albuterol. There was no history of fevers, vomiting, diarrhea, travel, or ill contacts. There was a family and personal history of asthma. Home medications at admission included Singulair, albuterol, and Epi-Pen.
Vitals were afebrile, oxygen (O2) saturation was 90% on room air. Examination showed increased respiratory effort with belly breathing and tachypnea. The patient was given 2 albuterol/ipratropium nebs, prednisone, and was started on 2 liters per minute (L/min) supplemental oxygen. Chest x-ray, complete blood count (CBC), basic metabolic panel (BMP), and flu testing was obtained. Chest x-ray showed peribronchial thickening with left-sided atelectasis versus infiltrate. Labs showed normal electrolytes, white blood cell (WBC) count was 7.8 with 81% segs and 14% lymphs. Flu swab was positive for Influenza B. The patient was started on Tamiflu, given supplemental oxygen, and admitted to the pediatric ward. The patient was discharged home on Tamiflu and prednisone in addition to his regular daily medications.

The health plan's determination is overturned. 

Yes, the requested inpatient stay is considered medically necessary for this patient.
This is a child with known asthma who presented to the ED with acute respiratory distress despite initiation of outpatient nebs. He had hypoxia on arrival to the ED and was found to be positive for influenza B. This child with asthma and influenza was at high risk for medical complication, and required close monitoring, supplemental oxygen, and respiratory treatment that a pediatric inpatient level of care will provide.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea, Tachycardia
 
Treatment: Inpatient Hospital

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

This is a female patient who presented to the Emergency Room (ER) with complaints of shortness of breath and tachycardia. She has a past medical history of diabetes mellitus, hypertension, high cholesterol, coronary artery disease, ischemic cardiomyopathy, cerebrovascular accident (CVA), and obesity. The patient was evaluated by Cardiology. An echocardiography was performed which revealed mild left ventricular systolic dysfunction, with an ejection fraction of 45-50%, mild hypertrophy, and mild diastolic dysfunction.  Her laboratory work up revealed normal biomarkers. A gastroenterology consult was performed for her iron deficiency anemia. The patient was discharged the following day when deemed medically stable. 

The patient presented with dyspnea and tachycardia, however, the initial evaluation in the emergency room (ER) was unremarkable, including negative cardiac troponin and a non-diagnostic electrocardiogram (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. Further evaluation was warranted, however, inpatient admission criteria were not met. Although the patient had new onset symptoms, medical policy criteria were not met for any other additional extenuating circumstances. There were no other high-risk co-morbidities.

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 in Part

This is a patient with a history of hypertension, reactive airway disease and anxiety, who presented to the emergency department complaining of chest pain.  There were no acute electrocardiographic changes.  Her serum troponin level was elevated.  A chest x-ray showed no acute disease.  She was admitted to the hospital with a diagnosis of non-ST segment elevation myocardial infarction.  The health plan's determination is overturned in part.  The patient required inpatient level of care for 1 day with discharge the following day.
This patient presented with chest pain and a significantly elevated serum troponin level. While she had no acute electrocardiographic changes, this did not rule out an acute infarction.  A normal electrocardiogram has been reported in up to 5% of patients with non-ST segment elevation myocardial infarction.  There were no obvious causes of a falsely elevated troponin level, such as renal failure, sepsis or congestive heart failure.  Until proven otherwise, in the setting of acute chest pain, an elevated serum troponin level must be assumed to be indicative of myocardial injury.  Given the risks associated with acute myocardial infarction, including potentially lethal arrhythmias, heart failure and shock, the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes recommends inpatient admission for patients with chest pain and elevated cardiac biomarkers in whom acute infarction is suspected.  However, given that this patient was found to have no obstructive disease, and her procedure was uncomplicated, she could have been discharged the next day, once she recovered from the procedure.  The safety of same day discharge after cardiac catheterization, even in the setting of percutaneous intervention, has been well established.
Appeal type: Medical necessity
Decision: Upheld

Abdominal/Stomach Pain
Inpatient hospital

This is a male with history of diabetes mellitus, hypertension, alcohol abuse, opioid abuse, chronic pancreatitis, bipolar disorder, chronic kidney disease (CKD), recurrent acute kidney injury (AKI) and appendectomy who presented to the emergency department (ED) with complaints of abdominal pain, nausea, vomiting and diarrhea. The patient reports that symptoms began 3 days prior and worsened with eating. Initial vital signs were blood pressure (BP) 158/94, pulse 97, resp 20, temp 99.3 F, and oxygen saturation 99%. Physical examination revealed mild right upper quadrant (RUQ) abdominal tenderness. Abnormal labs included hemoglobin 9.9, hematocrit 28.7, alanine aminotransferase (ALT) 91, aspartate aminotransferase (AST) 68, GGTP 324, creatinine 1.7, and alcohol level 167.8. Abdominal ultrasound imaging revealed no changes. The patient was treated with intravenous fluids, Zofran and Librium taper. The patient's condition improved and he was discharged home.

The health plan's determination is upheld. Based on review of the available documentation, the inpatient stay was not medically necessary. This patient was acutely intoxicated and was symptomatic due to the alcohol abuse. There was no evidence of alcohol withdrawal. The patient was hemodynamically stable with no evidence of decompensation. This patient could have been monitored and treated at a lower level of care. Symptomatic treatment of nausea, vomiting and diarrhea did not require inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

The patient was admitted to the hospital. The patient has a past medical history of diabetes mellitus, hypertension and hyperlipidemia. The patient presented with frequent urination and pressure for 2 weeks and also reported chills. Vital signs showed a blood pressure of 145/78, pulse 112, temperature 100.1 and oxygen saturation 98%. Chest x-ray showed no evidence of pneumonia. Labs showed a lactate of 3.73, hemoglobin 13, platelets 226, white blood cell count 10.8, sodium 133, bicarbonate 17 and creatinine of 0.9. Cultures were obtained and the patient was started on intravenous fluids and antibiotics. The patient was admitted for further management.

The health plan's determination is overturned. The inpatient stay was medically necessary. The patient's severity of illness upon presentation did necessitate an inpatient admission. The patient presented with frequent urination and pressure. The patient was febrile, tachycardic and had elevated lactate level along with bandemia. There was also a concern for pyelonephritis. The patient was treated with intravenous fluids and antibiotics. Blood cultures were also positive and the patient slowly improved. The patient was switched to oral antibiotic and discharged. Given the clinical presentation consistent with sepsis, the requested inpatient stay is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

This patient presented with atypical chest pain that was of new onset.  He was noted to be normotensive on examination. No other abnormalities or findings consistent with an acute coronary syndrome were noted.  Based on history and presentation alone, this patient had a low short term risk of death and nonfatal cardiac ischemia (Reference 1). No evidence of ischemia was noted on myocardial imaging. These findings are consistent with a low one-year mortality and a low probability of significant coronary artery disease (Reference 2). Utilizing the HEART (History, EKG, Age, Risk factors, initial Troponin) score, he is considered low risk (3 points) (Reference 3).  Utilizing the TIMI (thrombolysis in myocardial infarction) risk score, he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 4). 

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al (Reference 4).  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, the patient could have been managed at a lower level of care, as the Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a history of diabetes and benign prostatic hyperplasia (BPH).  He presented for an elective procedure.  He underwent a percutaneous nephrolithotomy.  There were no intraoperative and postoperative complications.  The patient had an uneventful hospital course and was discharged the next day.  The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld.

The inpatient stay was not medically necessary for this patient.  The majority of patients who undergo percutaneous nephrolithotomy can be discharged within 24 hours of the procedure.  The procedure was an elective scheduled procedure.  The patient did not have any significant risk factors which increase risk of post-operative complications. His post-operative course was essentially normal without any significant complications or issues with pain control.  Management at a lower level of care status for this patient's clinical presentation and post-operative course is the safe, effective, generally accepted standard, and the most appropriate treatment option.  Admission status may be changed anytime, if the patient requires continuing services and monitoring and if the patient's condition is severe enough to require inpatient treatment.