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

This is a patient hearing loss. On the right side, she has severe to profound hearing loss. On the left side, she has mild hearing loss and the left sided hearing loss fluctuates. A computed tomography (CT) scan of temporal bone is normal. An ear exam is normal. A right sided cochlear implant has been proposed. The health plan's determination is overturned. The patient has right sided severe to profound hearing loss in the right ear. She is a candidate for a cochlear implant in her right ear due to this profound hearing loss. The Food and Drug Administration (FDA) has approved cochlear implantation for unilateral hearing loss. Implantation is considered standard of care in most major centers in the United States for unilateral hearing loss. The peer reviewed literature shows long term safety and efficacy of cochlear implantation for unilateral deafness.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Psychosis
 
Treatment:  Inpatient mental health treatment, medication, monitoring

The insurer denied the continued inpatient mental health treatment.  The denial was reversed.

This patient is male who was admitted to inpatient mental health treatment due to psychotic symptoms.  He was experiencing persecutory and paranoid delusions, disorganized thinking, and poor reality testing, insight, and judgment, medication noncompliance including refusal to take medications, withdrawn, irritable and angry mood, and bizarre behavior.  He had past psychiatric hospitalizations.  He eloped from the facility during triage process.  He was prescribed the medication Abilify, but he stated that he did not want to take the medication.  He refused to sign consent to talk to a friend to arrange for discharge.  He had a court hearing, and it was determined that he should remain inpatient for 5 additional days to try to arrange for discharge.  

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia indicates that patients are candidates for inpatient level of care when experiencing one of the following symptoms:  hallucinations, delusional thinking, disorganized thinking or behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior, or inability to adequately care for basic needs. This patient still had psychotic symptoms during the denial period, including persecutory and paranoid delusional thinking, disorganized thinking, poor reality testing, insight and judgment, thought blocking, refusal to sign consent for discharge planning and also refusal of medication, impoverished speech, bizarre behavior, and psychomotor retardation.  It was reported that he could not care for himself due to psychotic symptoms.  He continued to require 24-hour hospital treatment until discharge. 

Based on the above, the medical necessity for the continued inpatient mental health treatment services is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain; dizziness

Treatment: inpatient hospital admission

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

This patient is a man with a past medical history notable for hypertension and chronic obstructive pulmonary disease (COPD).  He presented to the Emergency Room (ER) with complaints of chest pain and associated dizziness.  He had lightheadedness when driving approximately two hours prior to arrival.  He took his blood pressure which was noted to be 144/100, similar to what was obtained in the ER.  An EKG showed no ischemic changes. Troponins were negative.  He was advised to follow-up with a Cardiologist as an outpatient.  He was counseled and discharged home.

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

The acute inpatient admission was not medically necessary.  The patient presented with chest pain; however, the initial evaluation in the ER was unremarkable, including a nondiagnostic EKG.  Inpatient admission was not medically necessary for this patient.  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.  

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

The patient has a medical history of hypertension, hyperlipidemia, anemia of chronic disease, and hyperuricemia. The patient presented to the emergency department with worsening nausea, generalized abdominal pain, and diarrhea with 4-5 non-bloody bowel movements per day for approximately one week. The patient had recently been started on omeprazole, clarithromycin, and amoxicillin for the treatment of Helicobacter pylori. Vital signs on presentation were unremarkable. Physical examination was notable for acute distress. Labs were notable for leukocytosis with white blood cell count of 11.2 K/uL, anemia with a hemoglobin of 10.8 g/dL, metabolic acidosis with bicarbonate of 17 mEq/L, elevated creatinine of 1.96 mg/dL, elevated amylase of 166 U/L, and elevated lipase of 123 U/L. The patient was admitted.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The admission was not medically necessary at the acute inpatient level of care based on the provided information. The patient had abdominal pain, nausea, and diarrhea consistent with acute gastroenteritis or Clostridioides difficile infection. However, there was no sustained hypotension, tachycardia, or other stigmata of severe volume depletion or sepsis. Clostridioides difficile toxin was negative. A Computed tomography scan of the abdomen ruled out toxic megacolon, and did not show pancreatitis, gastrointestinal perforation, abscess, toxic megacolon, or obstruction. Although uncomplicated Clostridioides difficile infection may have been present, the patient did not have gastrointestinal bleeding, peritonitis, abscess, fistula, sepsis, or other complications warranting inpatient level of care. The patient was appropriately treated for Clostridioides difficile infection with oral vancomycin and responded well, with improvement in symptoms and ability to tolerate oral intake. There were no complications of acute pancreatitis, which was not established given lack of lipase or amylase 3 times above the upper normal limit and lack of pancreatitis on imaging. The measures which were undertaken, such as observation, monitoring, labs, antibiotic administration, and intravenous fluid administration could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient was admitted for inpatient withdrawal management. The patient had been using opiates, sedatives, cocaine, and alcohol prior to admission. The patient stated on admission that he wanted to go to a program and was sent to this facility for services. The patient reported a history of anxiety and attention deficit hyperactivity disorder (ADHD) in addition to his substance use disorders. The patient was described as completing all written assignments, attending group meetings, and engaging in individual counseling sessions while in treatment. The alcohol withdrawal score was mild or minimal during subsequent days of hospitalization. The treatment was complicated by also being on methadone for heroin detoxification.

The health plan's determination is overturned. The Inpatient Substance Abuse was medically necessary for this patient. The patient had several important clinical factors that need to be considered:
	History of withdrawal seizures and seizure disorder
	Complication of concurrent management of withdrawal with benzodiazepines and opioids.

Using the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) tool:

Alcohol was the substance most likely to cause harm to self or others. The patient clearly met criteria for multiple substance use disorders including alcohol use disorder and opioid use disorder. The patient was using alcohol and drugs in amounts or frequencies that could cause imminent physical or emotional harm to self or others. The patient did require inpatient substance use disorder treatment for detoxification from alcohol with a history of withdrawal seizures. The patient also having and opioid use disorder made management of medications for opioid withdrawal and alcohol withdrawal complex, requiring inpatient care.
The patient could not be managed in an outpatient setting given his history of withdrawal seizures. The patient did require 24 hour medical supervision, stabilization, and regular vital sign monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Shortness of breath and cough
Treatment:  Inpatient admission
The proposed treatment was not medically necessary.

This patient with known non-ischemic cardiomyopathy presented with exacerbation of CHF with no evidence of hemodynamic compromise or hypoxemia or febrile illness in the setting of a recent episode of acute bronchitis versus community acquired pneumonia, which was treated with antibiotic and oral steroid.  His white blood cell (WBC) count was mildly elevated in the setting of recent steroid therapy.  There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), malignant arrhythmia or hemodynamic instability.  The patient did not require pressor support, ionotropic support, mechanical ventilation, etc.  He improved with medical therapy and was discharged.  Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Transient Ischemic Attack
 
Treatment:  Inpatient Admission 

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

This is a female patient who presented to the emergency department (ED) with complaints of severe persistent left sided weakness, palpitations for 2 days, and difficulty walking.  She has a history of diabetes, hypertension, hyperlipidemia, immune compromise, and Bell's palsy.  Upon arrival her vital signs were stable.  Her physical exam revealed no motor or sensory deficits with a positive facial droop.  She had a computed tomography (CT) scan of her head and a chest x-ray, which were both negative.  An x-ray of the spine showed a stable grade 1 anterolisthesis of L4 and L5 and a mild degenerative disc at L4-L5.  Neurology consulted on the patient and recommended a carotid Doppler study and the application of a soft collar.  The Doppler was performed which was normal.  Cardiology consulted on patient.  It was recommended that the patient continue on current medication regimen and maintain a low sodium diet.  The patient was safely discharged with aftercare instructions in place.

According to the referenced literature, a patient may be admitted when there is suspicion of a transient ischemic attack when there is evidence of focal neurologic signs or symptoms that persist or recur, hemodynamic instability, the patient has been diagnosed as having a stroke, there is altered mental status, there is cardiac arrhythmias of immediate concern, severe hypertension, or there is a need for parenteral anticoagulation.  Within the documentation, none of the above was present.  The patient underwent multiple laboratory and diagnostic studies upon arrival in the emergency department.  These were unremarkable, and the patient did not have any significant findings warranting inpatient admission.

The medical necessity for the inpatient level of care from is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncopal episode 
Treatment: Wearable cardioverter defibrillator 

Summary:
This patient presented with a severely depressed ejection fraction.  His clinical presentation and hospitalization did not suggest high risk features for sustained ventricular arrhythmia or syncope. Although external LifeVest defibrillators appear to be efficacious in treating patients with sustained ventricular arrhythmia, a recent study that enrolled high risk patients presenting with myocardial infarction failed to demonstrate a significant reduction in sudden cardiac death.(5)  Based on current available guidelines and clinical trial data, the proposed treatment was not likely to be beneficial for the patient.(6)  In conclusion, external LifeVest therapy was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency department (ED) with the complaint of abdominal pain, nausea and vomiting of 2-weeks duration. She has a history of sleeve gastrectomy.  Surgical and Obstetrics and Gynecology (OB/Gyn) consultations were obtained. A computed tomography (CT) scan was completed showing anatomic findings of sleeve gastrectomy and no acute pathology.  The health plan's determination is upheld. Her evaluation with examination, lab data and CT scan did not identify acute pathology that required inpatient admission. She was treated with IV fluid, pain and antiemetic medications with improvement. She was maintained in the hospital and remained clinically stable during this time. There is no clinical documentation to support the need for inpatient admission. The patient remained hemodynamically stable throughout this period of care, there was no fever, or documented complication.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
 
Treatment: Inpatient substance detoxification treatment, medication, monitoring

The insurer denied the continued inpatient detoxification treatment. The denial was reversed.

This female was admitted to inpatient substance detoxification treatment for substance detoxification. She had multiple withdrawal symptoms. She reportedly was using multiple bags of heroin per day and had recently relapsed after getting fired from her job. She reportedly was also using 1 gram of crack/cocaine. Her toxicology was positive for opiates, cocaine, amphetamines, and benzodiazepines. She had reports of depression. She was started on a Methadone taper and was later discharged. 

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. This patient was using multiple serious substances including large amounts of heroin daily and crack/cocaine. It was not likely that she could attend an outpatient substance detoxification treatment due to her continued use as she relapsed again. She was at risk for accidental overdose as well as severe withdrawal symptoms due to her large amount of substance use. She also had comorbid depression and had treatment for depression with medications. According to the LOCADTR, she did require 24-hour treatment as she needed and received detoxification medication to modify withdrawal and prevent severe withdrawal.  The patient had continued withdrawal symptoms during the denial period. 

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

The patient was admitted to the hospital.  The patient has a past medical history of hearing loss.  The patient presented with elevated blood glucose of 400, generalized weakness, weight loss, poor appetite, polyuria and polydipsia.  An electrocardiogram (EKG) showed normal sinus rhythm.  Chest x-ray showed no active cardiopulmonary process.  Vital signs showed a blood pressure of 115/68, pulse 65, respiratory rate 14, temperature 36.2 and oxygen saturation 97% on room air.  Labs showed a sodium of 136, potassium 5.9, creatinine 0.89, blood urea nitrogen (BUN) 25, bicarbonate 23 and glucose 445.  Urinalysis showed protein and glucose but no ketones.  Insulin was started, and he was admitted for further management.  Intravenous fluids were also started.  During the course of the hospital stay, the patient's glycemic control improved.

The health plan's determination is upheld.  The Inpatient stay was not medically necessary.  The patient's severity of illness upon presentation did not necessitate an intensity of service for inpatient admission.  Based on the review of the medical record, this patient could've been safely evaluated and treated with all medically necessary interventions provided at a lower level of care.  The patient presented with elevated blood glucose of 400, generalized weakness, weight loss, poor appetite, polyuria and polydipsia.  The patient was found to have a hemoglobin A1C of 17.3%.  The patient was diagnosed with new onset diabetes and was seen by endocrinology, who recommended long acting and pre-meals insulin.  The patient received diabetes education and was discharged.  No complicating events occurred during the stay.  There was no hemodynamic instability, acute renal failure, severe electrolyte derangements, need for continuous insulin drip, diabetic ketoacidosis or arrhythmia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Fibroids
Treatment:  Inpatient admission
The inpatient admission was medically necessary.

The patient is a female with abnormal uterine bleeding due to fibroids.  She underwent an uncomplicated robotic assisted total laparoscopic hysterectomy, bilateral salpingectomy, lysis of adhesions, enterolysis, and cystoscopy.  After surgery she had nausea and vomiting.  She had a Foley catheter in place.  She had a hemoglobin of 8.8.  By postoperative day #1 the nausea improved; her pain was controlled with oral medications; her diet advanced, and her Foley was removed.  Her hemoglobin was stable.  She was discharged home.

In review of the medical record and the current literature, the patient had nausea and vomiting post-surgery and was unable to tolerate diet.  Therefore, it would be medically necessary to admit this patient for an inpatient hospitalization overnight, as this would be the most appropriate level of service, considering the potential benefits and harms to the patient, and would be effective in improving her health outcomes after surgery.  Discharge would not be reasonable or of sound medical care until the patient was able to tolerate treatment/diet by mouth (PO).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory syncytial virus (RSV) illness
 
Treatment: Inpatient admission, medication, monitoring

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

The patient is a baby who was taken to the ER following a one-day illness with fever, cough and diarrhea. The child was reported to have a decrease in oral intake during the one-day illness. The patient was having wet diapers. Upon arrival in the ER he was noted to be fussy but consolable with normal pulse oximeter readings. There was evidence of belly breathing but no retractions or wheezing. The patient was crying with tears and the lips and mucous membranes were moist. The patient was treated for fever in the ER and blood testing demonstrated normal electrolytes and a normal white blood count. A test for influenza was negative but a RSV test was positive. A chest x-ray was consistent with a viral pattern with no evidence of pneumonia. The decision was made to admit the patient to treat dehydration and administer medication for fever and Albuterol every 4 hours. 
The patient did not receive a bolus of normal saline and had several clinical findings (tears, moist mucous membranes, normal capillary refill and wet diapers) which did not support a significant degree of dehydration. Electrolytes were normal. The mild degree of increased respiratory effort was consistent with a mild RSV illness and did not indicate the patient was in respiratory distress.  Despite the decrease in oral intake noted in the ER, the patient could have been treated with the standard one or two boluses of IV normal saline, which frequently improves acute dehydration. Following an additional period of observation in the ER with IV fluids and repeat administration of Albuterol, the need for admission to the hospital could have been avoided. The decision to admit the patient to the hospital for ongoing IV fluid and treatment with Albuterol every 4 hours for an RSV illness was not consistent with the standard of care for treatment of mild dehydration. After receiving bolus therapy with IV normal saline, the patient could have been safely discharged home with follow up with the pediatrician in 24 - 48 hours.
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: Upheld

Diagnosis:  Diabetes 
Treatment:  Inpatient stay
The inpatient stay is not medically necessary.  

This patient was referred at 25 weeks five days for admission for diabetes control.  There was no evidence of diabetic ketoacidosis or blood sugars in life-threatening range.  Documented blood sugars during the admission were not in a dangerous range.  There was no evidence of abnormal biophysical profile or abnormal fetal heart rate tracing.  The patient was started on insulin and discharged undelivered.  

Initiation of insulin therapy on an outpatient basis with ambulatory home glucose monitoring is the standard of care and can be accomplished safely in patients who do not have dangerously high blood sugar levels.  There is no evidence in the medical records that blood sugars were ever in a range that was an immediate threat to the health of the mother or the baby.  Therefore, the admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure; Anxiety
 
Treatment: inpatient admission

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

This patient is a female with a past medical history of polysubstance abuse and seizure disorder. The patient also had anxiety, as well as depression.  She was being seen for a follow-up. She had recently been admitted for a video electroencephalogram (EEG). This showed normal activity during that admission. She was complaining of increased anxiety and about having a seizure, which caused panic attacks. She stated she was going to be seen for a second opinion, and it was recommended she request anti-anxiety medication. The patient was prescribed the medication; Gabapentin and Keppra.  On physical exam the patient was noted to be alert and oriented. The physician detailed the patient was recommended to follow-up in six weeks. It was also recommended that due to her escalating anxiety that she make an appointment to see her psychiatrist.

According to the referenced literature a patient may be admitted to inpatient services when there is evidence of hemodynamic instability, hypertension requiring inpatient treatment, acute cardiac or peripheral ischemia, severe heart failure, cardiac arrhythmias of immediate concern, respiratory abnormalities, neurologic abnormalities such as uncontrolled seizures, new-onset severe neurologic findings, or other indications such as severe anemia or severe electrolyte abnormalities. A review of the documentation indicates none of the above conditions. While documentation was submitted for review, there is lack of documentation specific to the admission.

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

The carrier's denial of coverage for the inpatient admission is upheld. The medical necessity is not substantiated.