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

Diagnosis: Syncope
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

The patient is a female.  She has a past medical history significant for HTN (hypertension), dyslipidemia and Takotsubo cardiomyopathy three years ago (catheterization revealing normal coronaries, subsequent echo three years ago - EF [ejection fraction] recovered to 63%). She presented for evaluation of dizziness and lightheadedness of one week duration. She reported her BP (blood pressure) medication was recently increased. 

The patient was hemodynamically stable and afebrile. In the ED, patient was found to have frequent PVCs (premature ventricular contractions) in a pattern of bigeminy on ECG (electrocardiogram). Her cardiac enzymes were normal. Her potassium level was found to be mildly reduced, and she was given a potassium supplement. 

The patient was admitted for monitoring. A repeat echo was obtained and revealed normal LV (left ventricle) function with wall motion abnormalities. Her metoprolol dose was reduced to once a day and she was discharged home with a plan for outpatient follow-up.

The patient presented for evaluation of dizziness and lightheadedness. The diagnosis of an acute MI (mycoardial infarction) was ruled out by cardiac enzymes, which were negative. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. ECG revealed ventricular bigeminy, which resolved with supplementing potassium. Echocardiogram revealed normal LV systolic function. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission. The care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Other 
Inpatient hospital 

The patient with a past medical history significant for attention deficit hyperactivity disorder (ADHD), bipolar disorder, sleep disorder, and opioid abuse who presented to the emergency department with opioid overdose.
Reportedly, the patient took four 30 milligram (mg) pills of Oxycodone. According to the history and physical examination note, the patient came to the hospital with respiratory depression, obtundation, and cyanosis. The patient was given Narcan in the field  prior to the arrival to the emergency department. The health plan determination is upheld in whole .
The requested health service/treatment of inpatient hospital stay was not necessary in this clinical case because of the relative clinical stability during the entire hospital stay. This patient presented to the hospital after the patient  took 4 tablets of Oxycodone.
It was reported that initially, the patient  was lethargic, obtunded, and cyanotic. However, at the time of the initial evaluation and throughout the entire stay in the emergency department, this patient was afebrile and hemodynamically stable.
Because of the concerns for low respiratory rate, the patient was transferred to the intensive care unit with Narcan drip, primarily for observation. The Narcan drip was discontinued very soon since the patient's respiratory rate went up to the normal range.
Taking into consideration these facts, this patient required admission for a lower level of care primarily because of the transient abnormality in his respiratory rate. The rest of the clinical data did not show significant abnormalities requiring admission at an acute inpatient level of care.
Therefore, the review of the clinical data demonstrated that neither the acuity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care.
The admission for a lower level of care, even in the intensive care unit, was warranted to look for the signs of clinical deterioration considering transient abnormality in the respiratory rate. At the same time, the review of the clinical data did not support that the patient had any significant abnormalities to justify the medical necessity of the acute inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Prostate Cancer
Treatment:  Cancer Screening

The patient is a male with prostate cancer. He had the Oncotype DX Prostate Cancer Assay performed on 4/10/19.  The classification was low risk.  The clinical stage was T1c. The PSA was less than (<)10.  The subject under review is the medical necessity of the testing.

The health plan's determination is upheld.

No, the OncotypeDX prostate testing is not medically necessary for this patient.  Per American Urological Association (AUA) Guidelines, "14. Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance. (Expert Opinion)"  Guideline Statement 32: "Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up. (Expert Opinion)"

The patient in this case has a low-risk prostate cancer.

National Comprehensive Cancer Network (NCCN)NCCN Guidelines state that "In summary, although molecular test results can provide additional guidance to patients, only limited data of prostate cancer specific-survival are available, and whether patient outcomes are improved with use of these tests is unclear." ". . . any of these tests may be considered to aid management decisions, but they are not required for standard of care at this time."
Appeal type: Medical necessity
Decision: Upheld

PD: Orthopedic/Musculoskeletal
PT: Inpatient Admission
ST:Surgical Services

The patient had a long history of back pain radiating to the right leg related to a right lumber (L) L3-4 disc protrusion compressing the right L3 nerve root that was refractory to conservative measures. She was admitted for elective right L3-4 decompression and discectomy which was completed however, post-operatively she developed urinary retention requiring a foley catheter. She worked with physical therapist (PT) and was able to walk 150 feet with a rolling walker. Oral pain medications were administered as needed. The catheter was removed and the patient discharged home. At issue is the medical necessity of inpatient admission. 
No, the requested service/treatment of inpatient stay was not medically necessary for this patient. In this particular case, the patient could have been admitted as an ambulatory procedure with a planned overnight stay. Then she could have undergone a voiding trial and have been discharged that day if the trial were successful. If not, then the status could have been changed at that time to either a 48-hour observation or inpatient. If a foley had to be reinserted, and a urology consult obtained with the determination that it needed to remain in for a period of time, then the urinary catheter could have been managed as an outpatient.
Post-operative urinary retention (POUR) is a common occurrence after spine surgery occurring in anywhere from 5.6-38% according to the literature. (Golubovsky J et al and Altschul et al). It can lead to increased morbidity from infections, bladder overdistention and autonomic dysregulation as well as increased LOS (length of stay). Early identification and treatment, as occurred in this case with placement of a foley catheter, can avoid a number of these complications. However, foley catheters are in and of themselves associated with complications, most commonly infectious. Early voiding trials and the use of intermittent catheterization can help ameliorate the incidence of infection. (Saint et al and Hoke et al).
Appeal type: Medical necessity
Decision: Overturned

Cardiac/Circulatory Problems - Chest Pain
Inpatient Hospital

The patient is a male with no past medical history (PMH) who was admitted with complaints of (c/o) substernal chest pain associated with radiation to bilateral elbows and diaphoresis. Vital signs were remarkable for blood pressure (BP) 151/91. Physical exam was remarkable for body mass index (BMI) 38. Lab work remarkable for troponin of 0.047. Radiology studies, chest x-ray (CXR) showed no acute cardiopulmonary process, computed tomography (CT) chest demonstrated coronary artery calcifications, deep vein thrombosis (DVT) ultrasound (US) showed no evidence of deep vein thrombosis (DVT) bilaterally in lower extremities (LEs), transthoracic echocardiogram (TTE) was normal. Electrocardiogram (EKG) showed T-wave inversions and possible anterior ischemia, with significant new progression the day after admission. The patient was admitted for classic accelerating and unstable angina and treated with intravenous (IV) heparin, beta blocker, statin, acetylsalicylic acid (ASA), nitroglycerin, cardiac monitoring and gastrointestinal (GI) cocktail. The patient was transferred to another facility for left heart catheterization (LHC) based upon determined medical need for urgent procedure.

The health plan's determination is overturned.

The hospital stay was medically necessary at an acute inpatient level of care. This patient with multiple cardiac risk factors, including obesity, history of (h/o) tobacco abuse, elevated BP during admission, and coronary artery calcifications, presented to the emergency department (ED) with c/o chest pain, suspicious for unstable cardiac disease. He had progressive and concerning T-wave inversions on the EKG, had multiple coronary artery disease (CAD) risk factors, and troponin was elevated above upper limits of normal (ULN), giving a HEART score of 7, indicating a high-risk major adverse cardiac event (MACE) of 50-65%. Due to this patient's high risk for mortality associated cardiac events, chest pain, progressive EKG abnormalities, and elevated troponin, the patient was determined, by expert cardiology consultation, to likely have unstable angina, and was treated with IV heparin and referred for urgent LHC at outside hospital (OSH). Due to the patient's high risk for cardiac events, the need for urgent expert evaluation for possible intervention, continuous cardiac monitoring and close monitoring on IV heparin/anti-coagulation in anticipation of cardiac intervention, an inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The proposed treatment, inpatient admission, was not medically necessary.

The patient is a woman who presented to the hospital complaining of chest pain for over one year. On examination vital signs were stable and chest pain was reproducible when palpating the sternum.  No other abnormal findings were noted. Past medical history was significant for diabetes mellitus.  Electrocardiogram revealed no evidence of ischemic changes and serial cardiac enzymes were within normal limits.  Computed tomography (CT) of the chest to rule out pulmonary embolism was normal.  The patient was ultimately discharged with outpatient follow up.

This patient presented with atypical chest pain that was present for one year's time.  Chest pain was reproducible when the sternum was palpated. Based on history and physical examination her pretest probability of coronary artery disease is low. (Reference 1)  Utilizing the HEART score she was considered low risk (three points). (Reference 2)  Utilizing the TIMI risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (Reference 3) 

Risk assessment of patients presenting with chest pain and no significant ST changes on electrocardiogram (ECG) was reviewed by Hedayati et al. (Reference 3).  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.  Admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System/Neuromuscular Disorder - Other

Mental Health: Inpatient

The patient is a male who was stated to be "shouting and screaming" in the context of a diagnosis of Tourette syndrome. He received inpatient level of care for five days. The patient was reported to be "not doing well-not sleeping, impulsive, easily agitated." The record indicates that for the prior 8 months, the patient had been nonadherent to psychiatric medications including risperidone 1 mg by mouth daily at bedtime and citalopram 20 mg every morning. The patient stated that he came to the hospital to get back on medication and to get into "an apartment program." 

The initial mental status exam indicated that there was no suicidal or homicidal ideation, intent, or plan. The patient was not documented to have any unstable medical problems or any issues related to withdrawal from substances. A physical exam showed that his teeth were intact and his mouth was without lesions. This is despite there being a statement that the patient needed to be urgently seen by a dentist for fitting of a mouth guard related to Tourette syndrome. The patient was described as receiving individual, group, and milieu therapy. He was described as participating in groups and taking medications.

The health plan denied the inpatient stay as not medically necessary. 

The health plan's determination is upheld. Essentials for a continued hospitalization include the diagnosis of a psychiatric disorder as defined by both the criteria of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM)-55. Among many others, these guidelines include as requirements:
1) The psychiatric disorder must be of such severity as to cause significant impairment of daily functioning in at least two important areas of the person's life such as work performance, social interactions, or family relationships.
2) The treatment proposed must be relevant to the problems diagnosed and adjudged likely to benefit the patient.
3) Other available less restrictive treatment resources must have been considered and determined to be not available or not appropriate to the patient's needs or have been attempted and proven unsuccessful. Examples of less restrictive treatment resources would include, but are not limited to, residential treatment, day treatment, or intensive outpatient care.

The clinical documentation that has been provided does not establish medical necessity for inpatient hospitalization. The patient was described as shouting and screaming and having tics related to his Tourette's syndrome. Clinical documentation does not establish that this posed a threat to his health or safety. The patient could have been safely and effectively treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the hospital with a chief complaint of dizziness. He had a history of peripheral vascular disease status post bypass with toe amputation. He stated that he was at work when he bent forward and began feeling dizzy. He reported two similar episodes over the past year. He also complained of pain in the upper leg after walking two city blocks. He denied syncope, loss of consciousness, fevers, chills, nausea, vomiting, chest pain and shortness of breath. Vital signs showed a blood pressure of 142/77, heart rate 67, temperature 98.1 degrees Fahrenheit, and respiratory rate 18. On physical examination, he was sitting comfortably on a stretcher, peripheral pulses were intact bilaterally, heart was regular, breath sounds were normal. A computed tomography (CT) scan of the head was negative for acute findings. A chest x-ray was negative for pneumonia. The patient was admitted with dizziness/peripheral vascular disease. The plan of care included telemetry, echocardiogram, aspirin, atorvastatin, cardiac enzymes, and continuation of other home medications. Cardiac enzymes remained negative and he had no events on telemetry. At issue is the medical necessity of an inpatient stay. The health plan's determination is upheld.
The patient had no abnormal head CT imaging findings, no abnormal electrocardiogram (EKG) findings, no abnormal telemetry findings, no evidence of sepsis, and no evidence of acute seizures or other acute causes of dizziness. He received a diagnostic evaluation and was continued on his home medications. He did not have a medical acuity consistent with the inpatient level of care. He primarily received a diagnostic evaluation and had no significant interventions performed during the hospital stay. In addition, he was ruled out for an acute stroke and other acute etiologies in the emergency department, including acute coronary syndrome and sepsis. He could have safely and effectively been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient hospital admission

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

This patient is a man with a past medical history notable for hypertension, hyperlipidemia, coronary artery disease, myocardial infarction, tobacco use, and diabetes mellitus. He presented to the ER with complaints of burning chest pain, described as continuous, associated with shortness of breath and diaphoresis. Vital signs were notable for blood pressure 145/105. He was noted to have a negative troponin but his EKG showed ST-elevation, possible early repolarization. He was taken to the cath lab for urgent cardiac catheterization, which showed no significant obstructive coronary artery disease. No revascularization was indicated. He was discharged home after a period of medical stability. 

The patient presented with chest pain.  The initial evaluation in the ER was unremarkable, including non-diagnostic EKG and cardiac biomarkers. He did not have definitive ST-elevation suggestive of acute coronary syndrome, but rather that of early repolarization in the setting of epigastric discomfort and normal cardiac troponin. 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 was 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 health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Anxiety Disorder; Bipolar Disorder

Treatment: Inpatient psychiatric hospital admission

The insurer denied coverage for inpatient psychiatric hospital admission. The denial reversed.

This patient is a man admitted for inpatient psychiatric treatment.  He was initially diagnosed with Anxiety Disorder.  He was discharged with the diagnosis of Bipolar Disorder. The insurer has denied coverage for the entire inpatient hospitalization.

The medical record indicated the patient had a four month history of paranoia and excessive fears about being killed by falling air conditioners.  He was noted to have bizarre and tangential thinking and periods of incoherence.  He reported auditory hallucinations.  He had been unable to stay at his home due to overwhelming paranoia and fear.  He reported severe anxiety, insomnia, and ongoing hallucinations.  He was being treated as an outpatient with Seroquel and IM aripiprazole.  There was a history of barbiturate and alcohol abuse.  There was a history of multiple Emergency Room and hospitalization admissions over the previous four months.  Following admission he was treated with an increased dosage of quetiapine and lamotrigine.  He showed improvement such that he was able to be discharged.

Based upon the information available the patient medically required acute inpatient psychiatric treatment. The patient had acute psychotic symptoms consisting of incoherent and tangential thinking, paranoid delusions and auditory hallucinations.  He had not responded to outpatient treatment, including oral and IM antipsychotic medications.  He could not safely conduct himself at home.  As such there were no safe or effective alternatives to treatment outside of acute psychiatric hospitalization. 

This finding is consistent with the general standards of psychiatric care as well as the American Psychiatric Association (APA) Guidelines for the Treatment of Patients with Bipolar Disorder.  The health plan did not act reasonably and with sound medical judgment and in the best interest of the patient in their determination to deny coverage for inpatient psychiatric care as of a specified date.  

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

Diagnosis: Chest pain

Treatment: Inpatient hospital admission 

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

This patient is a male with a history of diabetes, coronary artery disease, ectatic aorta, anxiety, depression, chronic obstructive pulmonary disease (COPD) and chronic opiate use for chronic back pain who was seen in the Emergency Room (ER) with a complaint of chest pain.  In the ER, the patient's blood pressure was 156/93, his temperature was 98.2, his pulse rate was 111, and his respiratory rate was 20.  He appeared agitated.  His blood urea nitrogen (BUN) was 19, his sodium level was 135, his creatinine was 1.1, his glucose was 557, his anion gap was elevated at 17 with a lactic acid of 7, and a venous blood gas pH was 7.37.  Troponin levels were negative.  It was planned to admit the patient; however, he left the hospital against medical advice.  The insurer denied coverage for inpatient hospital admission.

The case and the labs have been reviewed.  Calculation of the patient's plasma osmolarity was 307.73.  It is not sufficient for a diagnosis of hyperglycemic hyperosmolar state in which the plasma osmolarity should be >320 mOsm/kg.  The patient also was not in diabetic ketoacidosis, as his venous blood gas pH was 7.37.(1,2)   His lactic acid was high, suggesting lactic acidosis due to dehydration.  That suggests the need for ER care for intravenous (IV) fluid and insulin for a few hours and follow-up as an outpatient. 

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.  Based on the above, the medical necessity for the inpatient hospital admission from is not substantiated.  The insurer's denial is upheld.