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

Diagnosis: Chest pain, history of asthma, diabetes, hypertension, hyperlipidemia, sarcoidosis, morbid obesity, migraine headaches, and possibly hemiplegic migraine/stroke with residual left-sided weakness

Treatment: Inpatient admission, diagnostic evaluation, and medication management

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

This patient had a three week history of chest discomfort, described as pressure-like, radiating to her left side and back, worsened with lying down or coughing.  She was evaluated by cardiology with echocardiography and stress testing and had not yet been told of the results.  On the day of presentation she developed sudden onset of chest pain, accompanied by dyspnea, and Emergency Medical Services (EMS) were called two hours later, arriving at 05:07.

Initial vital signs at 05:14 included blood pressure (BP) 75/98, heart rate 117, and oxygen saturation on room air 98%.  Subsequent blood pressures obtained by EMS en route to the ED ranged from 145/85 to 147/104.  EMS administered aspirin and nitroglycerin patch and in the ED she also complained of an intractable headache with photophobia and neck stiffness.  EKG at 05:58 revealed normal sinus rhythm and flat T waves in V6.  Chest x-ray, CT angiography of the chest and abdomen, and CT scan of the head were unremarkable.  Echocardiography the next day was also normal.  She was treated for her migraine headache with morphine and Fioricet.  Laboratory test results at 06:10 included white blood count (WBC) 10.0, hemoglobin 13.0, creatinine 0.97, and troponin <0.015, with subsequent troponin at 12:20 also <0.015.  She was discharged home on aspirin, atorvastatin, folic acid and lisinopril, multiple vitamins, Trokendi, albuterol, Fioricet, and cyclobenzaprine.  

There is no evidence that this patient required an acute inpatient level of care to determine that her chest discomfort was not related to acute coronary syndrome or to treat her migraine headache.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain, past medical history includes type II diabetes mellitus and persistent asthma
 
Treatment: Inpatient admission, diagnostic evaluation, and medication administration

The insurer denied the inpatient stay. The denial was Upheld

The patient presented to the hospital with a chief complaint of intermittent right-sided chest pain, headache and cough of two weeks duration. He stated that the pain was 5/10 in intensity. He was diagnosed with diabetes mellitus in 2016. He reportedly does not follow up with his endocrine physician and is not compliant with his medication, since he frequently forgets to take his insulin. His physical exam did not reveal any abnormalities. Laboratory troponin level was within normal limits. His hemoglobin A1c was 10%. EKG done on day 1 showed sinus rhythm at 63 bpm. He was seen in consultation by the psychiatry department who noted that he has a history of depression and a childhood psychiatric history. The patient says that he sometimes feels depressed and he wants to change things but is not able to do so. The psychiatry consultant suggested routine observation and suggested starting Wellbutrin XL to treat both his depression and attention difficulties. He also recommended Seroquel for agitation. The patient was seen by cardiology consult and cardiac biomarkers were ordered and it was noted that his troponin was within normal limits. A transesophageal echocardiogram was ordered by cardiology but was canceled because the patient refused to take it. There were no acute changes on his electrocardiogram. Endocrinology was consulted for management of the diabetes and he was started on Lantus insulin before meals and metformin was discontinued the patient was closely monitored on the medical/surgical unit under the telemetry service until he was thought to be optimized medically for discharge. 

The literature also recognizes the use of an observation unit for this type of patient. However, a monitored level of care or telemetry unit is not the same thing and the literature cited shows that a monitored level of care (telemetry) for this patient was not necessary or appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol withdrawal
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

This patient presented to the ER for further evaluation/management s/p seizure episode and associated head trauma in the setting of EtOH abuse.  Intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air.  Examination was non-focal, with no significant abnormalities noted including no evidence of acute cardiopulmonary or neurologic abnormalities.  Laboratory testing was notable for moderately depressed hemoglobin/hematocrit, elevated blood alcohol level and moderately elevated liver enzyme levels, but no evidence of acute end organ damage.  Head CT and ECG were without acute abnormalities. 

The medical records indicate that this patient was admitted to the inpatient medical service in stable condition, where he received Librium PRN, IV fluids and electrolytes (banana bag) along with continued cardiac monitoring. He responded well to the prescribed therapies and was subsequently discharged in stable condition. 

There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome.  Hence, the proposed treatment of Inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient has no significant past medical history who presented to the emergency department (ED) on 1/19/19 with right lower extremity swelling, pain, and a non-healing wound. The wound started 2-3 months earlier after the patient opened up a "cyst" on the right lower leg. The patient has not seen a provider for the swelling or wound. The patient denies having any fever.

The health plan's determination is upheld. This patient does not meet Milliman Care Guidelines for DVT as the patient was not at high risk for bleeding due to anticoagulation,  had no evidence for a limb threatening thrombosis,  did not require thrombolytics, and an inferior vena cava (IVC) filter was not required. The patient could have been hospitalized safely at a lower level of care for 24 hours and then sent home with oral anticoagulation and an oral antibiotics.
Appeal type: Medical necessity
Decision: Upheld

The patient underwent elective coronary intervention (PCI) of an 80% left circumflex (CX) lesion. After successful intervention using a drug eluting stent patient was admitted to the hospital, monitored and observed uneventfully overnight, and discharged. Patient had had a recent coronary intervention on the right coronary artery (RCA) and underwent the CX PCI as a staged planned procedure.
HP determination of medical necessity is upheld. The complication within 24 hours after an uncomplicated elective intervention is much less than 1%.  There is a very high likelihood that the patient will be stable several hours after intervention and be able to be discharged. With these expectations of very low risk of complication and a short stay, a lower level status is reasonable for monitoring this type of patient.  Multiple studies have shown the safety of this approach. Therefore, inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
Inpatient level of care was not medically necessary.

This patient presented with atypical chest pain and dyspnea but no objective evidence of ischemia or hypoxia. While it was appropriate to rule out serious conditions for these symptoms, the testing performed and treatment given did not require an inpatient level of care. 

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome (ACS). Exam and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. CXR was normal. Echocardiogram showed no wall motion abnormality.  The physicians' treatment did not reflect treat for unstable angina.  Orders did not include medical therapy for ACS such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG).   

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry and an uncomplicated cardiac catheterization, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care.  The statement that this patient could not be "managed" in an outpatient setting is not consistent with guidelines or usual community practice. This patient had no evidence of coronary artery disease (CAD). All tests showed absence of ischemia.  While there is always a potential for an adverse event (and in this case a low probability), one did not happen and no actual treatment was added. There are no examples of care requiring inpatient level of care.

Milliman criteria requirements for admission for unstable angina were not fulfilled as there was never any evidence of ACS present. There is also no evidence that his presentation represented any cardiac disease. Calcium score represents a risk factor for CAD, but not angina itself. All further testing and therapy would be appropriate, safe and guidelines consistent in a lower level of care,

Inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, past medical history of hypertension as well as hyperlipidemia, sleep apnea, chronic kidney disease, and benign prostatic hypertrophy (BPH).

Treatment: Inpatient admission, diagnostic evaluation and medication management

The insurer denied inpatient admission. That denial was upheld

This patient presented to the Emergency Department with complaints related to hypertension.  The patient stated he was dizzy and had shortness of breath with an elevated blood pressure.  The patient woke up that morning to go to the restroom and felt dizzy.  When he attempted to put his continuous positive airway pressure (CPAP) machine back on, he felt like he could not tolerate it.  He then noted his blood pressure was elevated and did otherwise report two weeks of nasal congestion.  Upon physical exam the patient was well-appearing and in no apparent distress.  The patient had clear breath sounds and upon triage his vital signs revealed a blood pressure of 187/96 with a heart rate of 66 bpm.  The patient's oxygen saturation was 100% on room air.  The physician recommended diagnostic and laboratory studies.  The patient's chest x-ray was normal. It was noted upon re-evaluation in the emergency department that the patient's blood pressure did decrease to 167/95.  The history and physical indicated the patient had improved symptoms and the patient's labs were initially significant for a creatinine of 4.47 (baseline of 3) with potassium of 5.4.  He continued with treatment to include intravenous (IV) fluids and it was recommended to trend creatinine.  It was also recommended to add hydralazine as needed and hold losartan given the acute kidney injury.  It was noted the patient did have increased creatinine with an initial blood pressure of greater than 180. However, there is a lack of documentation detailing the patient had a new increase in creatinine (at least 3-fold) with reduction of more than 50% and estimated glomerular filtration rate from baseline.  Furthermore, the documentation indicated that repeat blood pressures did decrease significantly within an hour.  The patient's creatinine was likely due to dehydration which did down trend to 3.94. There was a lack of documentation supporting that the patient needed continued care at an inpatient level.  There was no documentation that the patient could not have continued treatment with IV fluid bolus within the Emergency Department while in observation level.
Appeal type: Medical necessity
Decision: Upheld

The patient had flank pain aggravated by micturition, associated with dysuria, increased urinary frequency, nausea and vomiting. She was admitted to the hospital. The health plan denied the inpatient admission as not medically necessary. The health plan's determination is upheld. An inpatient admission was not medically necessary. The patient had no hemodynamic instability, no documentation of bilateral renal obstruction, obstruction of a solitary or transplant kidney, no acute kidney injury, no intractable pain or vomiting, no urinary tract infection and no need for an inpatient surgical procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol use disorder
Treatment: 29 units of Residential Substance Use Treatment
The continued residential substance use treatment was not medically necessary.
The continued residential substance use disorder treatment for this patient was amenable to treatment at a lower level of care in a less restrictive treatment setting, and should be excluded from coverage under the plan. The patient was motivated and able to effectively engage in rehabilitation services, and, the patient did not need the continued structure or monitoring or intensity of services of a residential setting during the time interval under review. There were no biomedical or psychiatric complications, or severe psychiatric symptoms in this case that would have required the continued residential level services. The patient had access to rehabilitation treatment, sober housing or supports, and 12-step recovery self-help groups, and was motivated to continue to participate in rehabilitation treatment. Thus, the requested services are not consistent with prevailing standards of professional practice, or consistent with published practice guidelines (best practice) or the American Society of Addiction Medicine (ASAM) Criteria, referenced below, and are not in keeping with the appropriate application of NY State OASAS LOCADTR 3.0 Guidelines, referenced below
The continued residential substance use could have been effectively provided with lower level services in a less restrictive treatment setting in this case scenario.
In addition, the appropriate application of NY State LOCADTR Guidelines does not support the continued residential level treatment. This answer is also consistent with the guidelines and scientific literature and ASAM Criteria, referenced below.
Appeal type: Medical necessity
Decision: Upheld

The patient with history of hypertension and nephrolithiasis presented with complaint of flank pain. Had been seen the day prior with CT scan which showed non-obstructing nephrolithiasis. The patient was admitted given concerns for his pain and nausea. He was treated with pain medications and had abdominal ultrasound which revealed simple hepatic cysts. The health plan's determination is upheld.
The patient had abdominal pain and two episodes of vomiting without evidence of hemodynamic instability, urinary tract infection, or obstructing stones. He was able to eat and take oral medication. While the patient needed treatment, he could have been treated at a lower level of care and did not require and inpatient stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right lower quadrant pain
Treatment: Inpatient admission
The inpatient admission was medically necessary.
The medical records and medical literature were thoroughly reviewed. The patient underwent an exploratory laparotomy. Exploratory laparotomy is not an ambulatory procedure. The postoperative care of patients who have undergone laparotomy includes inpatient observation for postoperative complications including intra-abdominal hemorrhage, postoperative pelvic infection and progression to normal bowel function. Adequate analgesia can require IV pain medication, as in this patient, that also requires a more acute level of care. Normal return of bowel function after a laparotomy typically presents with bowel sounds occurring first, followed flatus and then by bowel movements. 
This patient underwent an uncomplicated laparotomy procedure. IV pain medication was given. She required an inpatient, acute level of care for appropriate postoperative management. Placing the patient in an observational or less than acute care setting would not have met the standard of care and could have adversely affected the patient's care. Provision of the treatment, in whole or in part, can reasonably be expected to be health beneficial for the patient and withholding the treatment, in whole or in part, can reasonably be expected to affect the patient's health adversely. 
Therefore, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: End stage renal disease, diabetes

Treatment: Inpatient admission, blood work, dialysis and medication management. 

The insurer denied the inpatient admission. That denial was upheld

This patient was transported by ambulance to the emergency room (ER) for complaint of worsening shortness of breath after missing her hemodialysis treatment.  The patient had a past medical history of diabetes mellitus and end-stage renal disease.  The patient reported being noncompliant with her home insulin regimen, her blood pressure was elevated at 193/125.  The patient was also tachycardic with a pulse of 119 bpm.  The patient had a glucose level of 653, an anion gap of 14, pH of 7.354.  The patient was admitted to medical ICU for management of hypertensive urgency and diabetic ketoacidosis in the setting of noncompliance with medication and missed hemodialysis treatment.  She received a hemodialysis treatment.  The next day  the patient signed out against medical advice reporting that there was no one to take care of her child.

The MCG have clinical indication for admission to Inpatient care for Diabetes and Hypertension.  For diabetic ketoacidosis all the listed criteria must be met.  In the clinical records submitted for review, the patient had glucose level of 706, Anion gap of 14, pH of 7.354.  Although the glucose level and the Anion gap met the criteria for inpatient admission, the patient did not have a pH or Bicarbonate level as indicated. In addition, there was no documentation of mental status not being at baseline, dehydration, vomiting, pregnancy, and the etiology of diabetic ketoacidosis was not unclear.  The patient reported having missed her hemodialysis treatment two days earlier.

The criteria for hypertension inpatient admission include systolic blood pressure (SBP) greater than 180 or diastolic blood pressure (DBP) greater than 120 with evidence of acute or worsening target organ damage indicated by one of many indicators listed.  The patient's blood pressure was 193/125. However, there was no evidence of acute or worsening target organ damage as indicated in the guidelines. 

The acute inpatient was not considered medically necessary for the patient because she did not meet the criteria for an inpatient stay per guideline criteria.  Although the patient did not meet the criteria for an inpatient hospital admission, a different level care such as observation admission may have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

This patient is a former 24-week premature infant with intractable epilepsy. The patient suffers post hemorrhage hydrocephalus and has a ventriculoperitoneal (VP) shunt in place. There have been numerous cranial procedures including shunt revisions and calvarium re-expansion. Other medical co-morbidities include reactive airway disease and retinopathy of prematurity.
An uncomplicated revision of the vagal nerve stimulator pulse generator was completed. Blood loss was minimal. The child was extubated readily and experienced no dyspnea or wheezing in the post anesthesia care unit.
The health plan's determination is upheld. 

The inpatient admission was not medically necessary for this patient.
Like many children with intractable epilepsy, stable medical co-morbidities were present. As there were no respiratory complications of the revision surgery, admission and overnight hospitalization was not warranted. The patient could have been safely and appropriately been treated at a lower level of care to establish clinical stability.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope
Treatment: Inpatient admission
The proposed treatment is medically necessary.
This patient presented with syncope resulting in head trauma.  The sudden nature of such an event is concerning.  Diagnostic testing revealed pre-excitation on electrocardiography consistent with Wolff Parkinson White syndrome.  This is a syndrome that can result in rapid conduction down an accessory bypass tract causing ventricular arrhythmia and even sudden cardiac death.   The abnormal electrocardiogram pointed to a cardiac etiology for syncope.  Although patients presenting to the hospital with syncope can often be risk stratified and rapidly discharged from the emergency department, those with cardiac syncope are at high risk of future events that result in increased morbidity and even mortality.  (Reference 1, 2)  Admission to the hospital and management at a higher level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Impacted tooth 
Treatment: Orthodontic treatment

The orthodontic treatment is not deemed medically necessary at this time.  

Without a proper, clear x-ray showing which tooth is impacted, and with no narrative from provider explaining which tooth is impacted, there is no medical necessity for the proposed treatment.

Without proof of impaction, there is no other need for orthodontic treatment in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, coronary artery disease

Treatment: Inpatient admission, diagnostic testing, medication management.

The insurer has denied inpatient admission. That denial had been upheld.

This patient had a history of recently noted coronary artery disease with proximal and distal right coronary artery stents in 2018. He presented to the Emergency Department (ED) at 14:40 with complaints of sudden onset of chest pressure and diaphoresis a few minutes prior to presentation similar to symptoms prior to his stents.  

The initial EKG is described as normal sinus rhythm with no ST-T changes.  A subsequent EKG in the ED was described as revealing new T wave inversions in III and aVF, which persisted during follow-up EKGs.  Laboratory test results from 15:52 included a troponin of 0.15, with subsequent troponin 0.14 at 20:18.  Echocardiography revealed mild left ventricular dilatation and a left ventricular ejection fraction of 49%.  He was seen by cardiology who recommended coronary angiography as an outpatient.  He remained hemodynamically stable and asymptomatic and was discharged on medications with his carvedilol dose increased to 6.25 mg twice daily.

Based on his clinical presentation and results of testing performed in the emergency department, there is no evidence that this patient was at increased risk for short term adverse cardiovascular events requiring inpatient monitoring and management.