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

Diagnosis: Alcohol Dependence 

Treatment: Inpatient Substance Detoxification. The insurer denied Inpatient Substance Detoxification. 

The denial was reversed.

This is a male patient who was admitted to inpatient substance detoxification treatment in early 2019 for alcohol detoxification treatment. He reportedly had withdrawal symptoms including nausea, sleeping problems, anxiety, teary eyes, and irritable mood and a Clinical Institute of Withdrawal Scale (CIWA) score of 9. He reportedly was drinking 400 ml of alcohol per day. He had a history of depression, and blackouts. He was unemployed and lacked coping skills. He was put on a 5 day Librium protocol for detoxification treatment. He left against medical advice (AMA) a few days after his admission.

The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. In this case this patient had been drinking alcohol daily and had withdrawal symptoms. 

According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as he continued to use alcohol daily despite past reported alcohol treatment including a recent inpatient detoxification treatment earlier that year. Also, he required and received detoxification medication including Librium to modify withdrawal and needed 24 hour treatment at that time as he was at risk for worsened withdrawal symptoms including severe, complicated, or life threatening withdrawals if not in this 24 hour setting. The risk of life threatening and complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required the entire time. He lacked coping skills and was unemployed.

Based on the above, the medical necessity for the inpatient hospital services at the Medically Supervised Withdrawal Service level of care is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Detoxification
 
Treatment: Inpatient Detoxification

The insurer denied the Inpatient Detoxification. The denial was reversed.    


This is a middle age male who was admitted to inpatient substance detoxification treatment in early 2019 for alcohol and substance detoxification. He reportedly had withdrawal symptoms including sweats, tremors, nausea, irritable and anxious mood, sleeping problems, elevated heart rate of 99, and elevated blood pressure of 141/83 and he had a Clinical Institute Withdrawal Assessment (CIWA) of 14. He reportedly had been drinking 1.5 pints of vodka per day and two 24 ounces of beer, smoking 7 joints of cannabis or hashish. He has a history of post-traumatic stress disorder (PTSD) and a past psychiatric hospitalization in a few years earlier. He had multiple past inpatient substance detoxification and rehabilitation treatments, most recently inpatient detoxification treatment a few weeks earlier. He reportedly had a positive toxicology for cannabis and benzodiazepines. He states he was unable to maintain abstinence on his own and lacked coping skills. He was put on a Librium protocol during this admission and completed it by date of discharge. He declined the follow up recommendation for inpatient rehabilitation and was discharged home.
According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as he continued to use large amounts of alcohol despite multiple past inpatient substance detoxification and rehabilitation treatments including a recent inpatient detoxification treatment. He required detoxification medication (Librium) to modify withdrawal as he was in active withdrawal with a CIWA of 14 initially. He needed 24 hour medical inpatient hospital treatment for safe detoxification as he was at risk for severe and life threatening worsened withdrawal symptoms. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required the time in this hospital as he was considered at high risk for life threatening withdrawal including delirium tremens. It was reported that he had detoxification medication (Librium) during this admission and was then discharged home.
Appeal type: Medical necessity
Decision: Upheld

The patient was admitted to the hospital with a diagnosis of paroxysmal atrial fibrillation. Other clinical problems included chronic bilateral lower back pain, GERD, and hypothyroidism.
The patient was evaluated by the cardiology service and was recommended treatment with Lovenox as well as cardioversion. Apparently, at the time when the patient was seen by the cardiologist, his heart rate was well-controlled. 

During the hospital stay the patient underwent left heart catheterization, which demonstrated no evidence of coronary artery disease. Subsequently, the patient underwent cardioversion. After the cardioversion, he remained in normal sinus rhythm for 24 hours and subsequently was discharged home.

Even though the patient was in atrial fibrillation, he had no signs of hemodynamic instability, myocardial ischemia, altered mental status, heart failure, persistent symptomatic tachycardia, or any other medical condition requiring admission at the inpatient level of care.

There was no evidence that the patient's atrial fibrillation was related to any medication toxicity. Even though the patient had orthopnea, there was no strong evidence that the patient had decompensated heart failure based on the results of the physical exam as well as diagnostic studies.

Taking into consideration all these facts, the admission did not require an inpatient level of care. The care could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain
Treatment: Emergency Room Visit

The proposed treatment (ED visit) is not medically necessary.

The patient presented to the ED with chief complaint of "neck numbness".

The prudent layperson standard states that ER services are medically necessary if a prudent layperson would have reasonably expected to have the following consequences in the absence of immediate medical attention. Pursuant to New York state law "emergency condition" means a medical or behavioral condition that manifests itself by acute symptoms of severity, including severe pain that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in:
A. Placing the health of the person in serious jeopardy; or
B. Serious impairment to such person's bodily functions; or
C. Serious dysfunction of any bodily organ or part of such person; or
D. Serious disfigurement of such person.

The symptoms that brought this patient to the ED on do not meet the prudent layperson standard for requiring emergency services. The patient had isolated neck discomfort. There had been no trauma preceding the onset of his neck pain. There were no associated symptoms to suggest to a prudent person that a medical emergency was present. There was no chest pain or shortness of breath. There was no weakness in either upper extremity. The patient was able to move his neck.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency department with complaints of a fall at home and the inability to ambulate. At the time of presentation, he had complaints of ataxia and the inability to ambulate. He denied dizziness or vertigo. A head computed tomography (CT) scan performed on presentation revealed no acute changes. The health plan's determination of medical necessity is upheld. There was no documentation that the patient had any progressive symptoms, and the patient did not undergo any specific stroke workup. The patient did not require any neurochecks. The patient did not require any other intensive neurological monitoring. The patient did not require any cardiac, hemodynamic, pulmonary or other medical monitoring. In the absence of evidence of that the patient had an acute stroke or any disorder that would result in neurological deterioration, the patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the hospital for an elective cardiac catheterization.  The patient described chest pain on exertion.  Stress test showed a moderate reversible defect in the anterolateral segment of the left ventricular (LV) on nuclear scanning.  The patient had a history of diabetes, hypertension, hyperlipidemia and previous stroke.  Heart catheterization on 4/8/19 showed a 90% first obtuse marginal lesion, which was treated successfully with a drug eluting stent.  The patient was observed uneventfully overnight and discharged.

The health plan's determination is upheld. The inpatient hospital admission was not medically necessary.  The patient had an elective uncomplicated catheterization and coronary intervention.  It was appropriate to monitor the patient post-procedure for several hours, but that could have been performed at a lower level of care.  It was expected that discharge would have been accomplished within 24 hours in this low risk patient.  An inpatient hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient is diagnosed with ulcerative colitis. The patient has had several years of disease and apparently had a poor response to anti-TNF (tumor necrosis factor) medications, thiopurines and budesonide. Approximately one year ago, he was started on Stelara and apparently experienced a good response - the provider would like to continue this therapy. By pathology from colonoscopy he has pancolitis. Interestingly, the colonoscopy shows evidence of ileal ulceration, rectal sparing, with narrowing at a surgical anastomosis. There were numerous pseudo polyps as well. Stelara is under review. 

The health plan's determination is upheld. There are currently no evidence-based data to support using Stelara for the management of Ulcerative Colitis. Phase 3 studies resulting in Food and Drug Administration (FDA) approval of Stelara were done in patients with Crohn's Disease. Alternative agents for the treatment of ulcerative colitis which have not been tried include vedolizumab and Xeljanz. Therefore, at this time, Stelara is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath/Asthma
 
Treatment: Inpatient Hospitalization
The insurer denied the Inpatient Hospitalization. The denial was upheld.
The patient is a female who presented to the Emergency Department (ED) in early 2019 with complaints of worsening shortness of breath (SOB)/asthma for the past two days.
The patient reported some fevers at home along with generalized body aches and productive cough.  The patient's past medical history included hypertension (HTN), hyperlipidemia (HLD), gastritis, and asthma. Vital signs at presentation were temperature (T) 38.3 Fahrenheit, heart rate (HR) 123 beats per minute, respiratory rate (RR) 18 breaths per minute, and blood pressure (BP) 128/82 millimeters of mercury.  Oxygen (O2) saturations were 96 % on room air (RA).  The patient was awake and alert.  Lungs were clear.  Cardiovascular system (CVS) S1 S2 +.  She was grossly intact neurologically. Corona Virus test was positive.  White blood cell (WBC) count was 8.12, hemoglobin (HB) was 13.2.  Chest x-ray showed no acute infiltrate.  Troponin was 0.1. The patient was treated with DuoNeb, and steroids in the emergency department (ED).  The patient improved with treatment. The patient remained stable after admission.  She was seen by Pulmonology the next day.  She was afebrile.  Heart rate (HR) was 93, blood pressure (BP) 130/75 mm Hg.  Oxygen saturations were 93 - 98 % on room air (RA).   Respiratory rate (RR) was 18.  The patient was in no acute distress (NAD).  Lungs had scattered wheezing.
This patient did not need acute hospitalization.  She could have been placed in observation status and diagnostic testing with treatment initiated.  This patient was stable for discharge by the next day.  She remained afebrile and hemodynamically (HD) stable.  There was no pneumonia.  Chest x-ray showed no infiltrate.  She was not hypoxic.  White blood cell (WBC) count was normal.  The patient was tolerating oral intake. She could have been discharged home on oral medications with close follow-up as an outpatient.  

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: Cough, decreased intake, drainage from ear
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
The baby presented to the ED with symptoms consistent with upper respiratory infection. She had several episodes of vomiting at home, generally post-tussive. She had appropriate vital signs and perfusion in the ED, with moist mucous membranes and well appearance. Laboratory evaluation revealed mild metabolic acidosis, in the context of difficulty obtaining the sample. She was diagnosed with mild dehydration without significant physical or laboratory evidence and treated in the ED with two fluid boluses nonetheless. While it may have been appropriate to monitor the baby for ability to tolerate feedings (e.g., Pedialyte, formula), she was overall hemodynamically stable with no respiratory distress, fevers, or signs of sepsis. She did not require acute inpatient admission, and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sarcoma; Abdominal pain
 
Treatment: Inpatient admission

The insurer denied coverage for Inpatient admission. The denial was reversed.

This patient is male who presented to the hospital early 2019 with complaints of abdominal pain as well as back pain.  The documentation indicated the patient does have a history of hypertension as well as gout, bone cancer and sarcoma.  He was undergoing chemotherapy and prior to admission he was diagnosed with a femoral artery clot and started Eliquis.  The documentation indicated the patient's last chemotherapy treatment was 4 days prior to presentation.  The documentation indicated the patient was recommended to undergo multiple laboratory diagnostic studies.  The documentation indicated the patient underwent a CT scan showing a thrombosis within the left common femoral vein.  Suspect lung, hepatic, and possible pleural metastases with fatty infiltration of the liver.  There was also 3.1 cm lesion within the L1 vertebra likely a cyst or giant cell tumor.

According to current literature a patient may be admitted when there is evidence the patient will undergo chemotherapy with expected toxicity, there have been chemotherapy complications, the patient is admitted with high risk of febrile neutropenia such as profound neutropenia anticipated to extend for greater than 7 days, hypoxemia, hemodynamic instability, tachypnea, altered mental status, new onset abdominal pain, and platelet count of less than 50,000, severe anemia, when there is a high risk infection or there is evidence of severe electrolyte abnormalities.  Within the documentation it was noted the patient's potassium was 2.6 and magnesium was 0.6.  The documentation detailed the patient was also tachycardic.  The documentation does detail the patient had a new onset of abdominal pain as well.  The patient was also noted to have an elevated lactate.  It was thought the patient was septic and therefore he was admitted for further electrolyte correction.  The documentation does detail the patient met the clinical indications for admission to inpatient services given the above.

The patient did not stabilize until after admission when palliative care was set up and discussed.  Therefore, given the documented electrolyte imbalance as well as vital sign abnormality and diagnosis of sarcoma with neutropenic fever the patient's admission and treatment was appropriate.  The patient continued to have deficits needing inpatient hospitalization given the high risk of continued complication.  Therefore, the inpatient admission from was medically necessary.

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

Based on the above, the medical necessity for inpatient admission is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

The patient is a male, who was admitted following medical screening to inpatient level services for monitoring and detoxification and withdrawal management of opioid (prescription opioids) and cannabis use disorder (marijuana).  He was using 5 to 10 milligrams (mg) of oxycontin on a daily basis since age 19 years together with two joints of marijuana daily with onset of cannabis use disorder in early adolescence.  The patient presented with moderately severe opioid withdrawal at the time of admission with a Clinical Opiate Withdrawal Scale (COWS) scale score of 18.  He had severe withdrawal symptoms in the past when attempting to stop or curtail his use of the oxycontin.  He had not participated in past treatment for the substance-related conditions.  The health plan's determination is overturned. 

The inpatient detoxification treatment and withdrawal management for severe substance use disorder and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care.  The adult inpatient treatment of this patient's substance use disorders did warrant the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorders with associated psychosocial stressors and impairment of functioning.  Withdrawal symptoms were managed with a Suboxone protocol requiring monitoring and as needed (prn) medications, as well as the availability of comfort medications and vitamin replacement therapy.  Counseling and educational sessions with motivational techniques together with case management services were appropriately provided to motivate the patient's transition to rehabilitation substance use disorder treatment.  Thus, a safe and effective detoxification with withdrawal management during the time frame under review with associated substance use disorder treatments were considered medically necessary in this case, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Influenza Viral Infection
 
Treatment:  Inpatient Admission

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

This is a female patient who presented to the Emergency Department in 2019 with complaints of lightheadedness, weakness, and feeling faint.  The patient also reported difficulty inhaling and feeling as though her chest was closing up.  She reported a similar episode three days prior to presentation.  The patient tested positive for Influenza A.  The patient had a history of a cardiac stent placement in 2005 that was replaced in 2012.  The patient was admitted for an influenza viral infection.  She received intravenous fluids and Tamiflu.  A chest x-ray was negative.  Troponins and an EKG were negative for any acute findings.  Cardiology consulted and recommended an echocardiogram as an outpatient.  The patient remained hemodynamically stable.  She was discharged to continue outpatient management.

Based on above findings, the patient was clinically stable for continued outpatient management once the diagnosis of influenza A was established while in the ED.  Based on the above, the medical necessity for the inpatient hospital services is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia; dysphagia
Treatment: Consumer Directed Personal Assistance Program (CDPAP); 12 hours per day- seven day(s) per week; 12 hours per day - seven day(s) per week (split-shift) - a total of 168 hours per week

The proposed treatment of Consumer Directed Personal Assistance Program (CDPAP); 12 hours per day - seven day(s) per week; 12 hours per day - seven day(s) per week (split-shift) - a total of 168 hours per week, is deemed medically necessary. 

This female has a history of cognitive impairment secondary dementia and associated gait ataxia, frequent falls and dysphagia with risk for aspiration. For these reasons, she requires home health caregivers for assistance in completing her numerous activities of daily living (ADLs). Furthermore, the medical records demonstrate significant functional and cognitive decline supporting the need for increased home health aide hours to prevent potential falls, aspiration and other safety issues. For these reasons, the requested health service of Consumer Directed Personal Assistance Program (CDPAP); 12 hours per day - seven day(s) per week; 12 hours per day - seven day(s) per week (split-shift) - a total of 168 hours per week, is deemed medically necessary and indicated to better assist with completion of her various ADLs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Unspecified Transient Ischemic Attack 

Treatment: Inpatient Admission

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

This is a male patient who presented to the emergency room with complaints of weakness and dizziness, right hip pain radiating down the right leg and difficulty speaking that lasted for about 45 minutes. He was admitted for an unspecified transient ischemic attack. He has a history of diabetes mellitus, hyperlipidemia, hypertension, anemia and non-alcoholic steato-hepatitis. He had a Computerized Tomography of his brain resulting normal, an ultrasound of the bilateral carotid arteries showed no blockage and neurological examination was within normal limits. Neurology was consulted and the impression was a new onset seizure disorder. Keppra was administered twice a day at 750 milligrams a dose. A rehabilitation consultation was done, however, the hemiparesis and dysarthria had resolved. The patient was discharged in stable condition.

The Milliman Care Guidelines (MCG) for TIA state that inpatient admission is recommended for hemodynamic instability, neurologic signs or symptoms that persist or recur, a stroke is diagnosed; findings on brain imaging that require inpatient care, altered mental status, or cardiac arrhythmias of immediate concern.
The MCG for Seizure state that inpatient admission is recommended for repetitive seizures not controlled with emergent treatment, etiology that requires monitoring or intervention available only at inpatient level of care or that persists despite observation care, new focal neurologic deficit, recurrent seizure activity during the emergency department or observation care.  

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.