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

Diagnosis: Arthritis and Dyspnea

Treatment: 84 hours of Consumer Directed Personal Assistant Services (CDPAS)

The insurer denied the 84 hours of Consumer Directed Personal Assistant Services (CDPAS). The denial was reversed. 

This is a middle aged female patient who is status post sinus tarsi debridement right foot, hardware revision in mid-2019. She has a history of arthritis in both knees, chronic bilateral low back pain without sciatica, scoliosis, dyspnea on exertion, gastroesophageal reflux disease (GERD), hypertension, depression, morbid obesity, pain in both elbows, game finger's thumb, left, radiculopathy with lower extremity symptoms, anxiety, and renal stones. It was documented that the patient ambulated independently with the assistance of a walker/cane.  Per the Uniform Assessment System-New York (UAS- NY) Comprehensive Community Assessment Report dated early 2019, the patient moved in and lived with her son and daughter who was one of her aides. In addition, the patient's needs were noted as: total dependence for meal preparation, ordinary housework, managing finances, shopping, and transportation; independence with bed mobility, eating, locomotion, and toilet transfer; and limited assistance with personal hygiene. The care management (CM) progress notes from early 2019 state that the patient reports pain on the bottom of her feet when she stands too long; and is also experiencing vertigo. She plans to discuss this with PCP. It was also noted that patient requires help getting upstairs to the bathroom where there is a shower. 

One ADL that presents a concern is toilet use which was assessed in early 2019, UAS as needing extensive assistance. The need to use the toilet is not a scheduled task and is not limited to a few hours per day. If the patient does not have someone to provide assistance for extended periods of the day, then it is not clear how she can safely and effectively manage to use the toilet. In early 2019 UAS noted the patient needed supervision for stairs, but the CM notes from mid-2019 state that patient needs one person assist with stairs. This indicates a functional decline from early 2019, and raises the question as to whether other mobility/weight bearing ADLs may also require more assistance. 

Based on the above, the medical necessity for the 84 hours of CDPAS is not substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

The patient presented to the hospital with acute complaints of left lower extremity (LLE) pain and swelling.  During the course of an evaluation, the patient started having chest pain and required a computed tomography (CT) chest, which is when the patient was found to have developed a pulmonary embolism with evidence of right ventricular overload as referenced by having a flattening of the interventricular septum.

The health plan's determination is overturned.  The inpatient stay was medically necessary.  A lower level of care is not appropriate in the case of submassive PE due to the potential for rapid decompensation.  The therapy provided to the patient was appropriate for his diagnosis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ideopathis short statute

Treatment: Growth hormone

The insurer denied the Medication Genotropin. That denial was upheld

The patient's was diagnosed with Idiopathic Short Stature.  Growth hormone in the treatment of idiopathic short stature is supported by randomized controlled trials and consensus guidelines.(4-9) FDA approval for this indication is for "non-growth hormone-deficient short stature, defined by height standard deviation less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

The patient does not have a pre-treatment height less than or equal to -2.25 SD.  The patient therefore does not meet idiopathic short stature criteria. Genotropin is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

Acute febrile illnesses are common in infants and young children, and represent the gamut of pathology, from self-limited viral infections to serious bacterial infections, such as pneumonia, pyelonephritis, and meningitis.  Neonates less than 28 days of life represent a special group of patients because of difficulties assess behavioral state, decreased immunologic function, and higher frequency of serious bacterial infections in this age group.  Neonates that present with fever require a full sepsis evaluation including blood, urine, and cerebral spinal fluid (CSF) cultures, followed by hospitalization with or without antibiotics pending culture results.  Infants outside of the neonatal period but less than three months of age fall into a more complicated group because infants less than two months of age have higher incidence of serious bacterial infections, but infants meeting low risk criteria may be manageable in the outpatient setting.  Risk criteria are helpful tools, but studies have shown failure to identify serious infections such as meningitis and urinary tract infection.  In academic settings, febrile infants one to three months of age deemed low risk may be managed in an outpatient setting.  However, in the community, it is still common practice to hospitalize febrile infants older than one month and less than three months with or without antibiotics pending culture results.

As a neonate, this little baby developed fever to 38.1 with no other symptoms.  Per the current standard of care, a full septic work-up was indicated followed by close monitoring pending culture results because of the risk of serious bacterial infection.  The baby was overall stable, with no evidence of dehydration, respiratory distress, or hemodynamic compromise.  He did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Inpatient Admission
The proposed treatment, inpatient substance abuse rehabilitation admission was not medically necessary for this patient in keeping with NY State OASAS LOCADTR 3.0 Guidelines/Criteria.
The inpatient substance abuse rehabilitation treatment, in this case scenario, was amenable to treatment at a lower level of care. The patient was externally motivated and able to effectively engage in rehabilitation services, and, the patient did not need the structure or 24-hour monitoring of an inpatient setting in order to safely and effectively participate in rehabilitation substance abuse treatment. There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted inpatient level services and treatment. Moreover, the patient had good family support for his involvement in the substance use disorder treatment, as noted in the clinical summary. Thus the requested benefit of inpatient substance abuse rehabilitation admission was not medically necessary for this patient.
This answer is consistent with prevailing standards of professional practice, the American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, as well as New York State instruction for medical necessity reviews together with the NY State OASAS LOCADTR 3.0 Criteria, applicable in this case.
The structure and intensity of services necessary for a successful rehabilitation/substance use disorder treatment can be/could have been effectively provided at a lower level of care in a less restrictive treatment setting with sober supports. There is no evidence that inpatient level structure and 24-hour monitoring is medically necessary for a successful outcome in this case.  And, there were no biomedical, psychiatric or general medical issues that warranted the admission and the continued inpatient level treatment in this case scenario.
Thus, as the health plan asserts, the patient's cannabis and alcohol and tobacco/nicotine use disorders were amenable to treatment at a lower level of care in this case scenario, and the health plan's determination of medical necessity was consistent with the application of NY State OASAS LOCADTR 3.0 Criteria.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain with prior surgical history of an L4-L5 discectomy ten years prior to presentation

Treatment: Inpatient admission, diagnostic testing

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

This case involves a patient who presented to the Emergency Department complaining of back pain since the day prior to presentation. She stated her pain radiated into the buttock and down her left leg.  She also complained of tingling.  She stated that she utilized oxycodone and Flexeril without relief.  She does have a prior surgical history of an L4-L5 discectomy.  The patient did not have any complaints of incontinence.  The patient was in no apparent distress.  The patient did have tenderness to palpation to the left lumbar paraspinous muscles, as well as the left hip.  There was decreased range of motion.  There were no motor or sensory deficits.  It was recommended that the patient receive intravenous dexamethasone, as well as ketorolac.  The patient did undergo an x-ray that did not reveal any acute findings.  An MRI also revealed L4-L5 mild left foraminal narrowing with no focal disc herniation or spinal stenosis.  The patient continued to complain of severe pain and was unable to walk. 

According to current literature, a patient may be admitted to inpatient services when there is evidence of a progressive or severe neurologic deficit, spinal fracture, suspected spinal infection, or severe pain requiring acute inpatient admission as evidenced by pain unresponsive to non-opioid analgesic and non-pharmacologic therapy, as well as oral transdermal or submucosal route not appropriate or not sufficient, and there is anticipated titration not appropriate for lower level of care when there is evidence of a suspected new or deteriorating disease process.  Within the documentation, it was noted the patient did present with complaints of severe pain.  The patient was initially medicated with intravenous dexamethasone, as well as ketorolac.  The patient also received Dilaudid and morphine.  She continued to complain of severe pain and was admitted.  However, it does not appear that the patient could not have been treated at a lower level.  The documentation did not detail the patient to continue to receive intravenous (IV) morphine or other IV opiate pain medication outside of the Emergency Department.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting and abdominal pain

Treatment: Inpatient admission, diagnostic evaluation, and medication management

The insurer denied admission. That denial was upheld.

This patient presented to the emergency department complaining of left lower quadrant pain.  The patient had one episode of vomiting.  The physical exam revealed the patient was in no distress.  The patient did have left lower quadrant tenderness on exam.  There was no rebound or guarding.  The patient had normal bowel sounds in all 4 quadrants.  The recommendation was made for the patient to undergo laboratory and diagnostic studies.  The pelvic ultrasound revealed no adnexal masses or abnormal pelvic fluid.  A renal and bladder ultrasound revealed no evidence of hydronephrosis.  A CT scan of the abdomen did reveal minimal prominence of the distal appendix.  It was noted the patient may have an early appendicitis.  The patient continued to complain of abdominal pain, and was recommended for admission.  The patient began treatment with IV fluids and was kept NPO.  The patient did undergo consultation by gastroenterology.  The recommendation was also made for the patient to undergo a colonoscopy due to the possibility of colitis.  There were no complications from the procedure and the colonoscopy was normal.  The patient, the following day, was noted to be comfortable.  The patient's symptoms had improved, and her white blood cell count was normal.  It was recommended the patient advance her diet.  Surgery determined surgical intervention was not going to be required.  The patient was discharged.  

According to current literature a patient may be admitted to inpatient services when there are peritoneal signs, hemodynamic instability, signs of intestinal obstruction, bacteremia, the inability to maintain oral hydration or surgery is needed that cannot be performed on an ambulatory basis.  There was no indication that the patient had any of the above indications.  

The patient did present with complaints of left lower quadrant pain. However, there is no indication the patient needed surgery that could not be performed on an ambulatory basis.  Furthermore, there was no evidence of severe pain that required acute inpatient management.  Therefore, while observation may have been an appropriate intervention for this patient, the inpatient services were not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD) and congestive heart failure with a left ventricular ejection fraction of 30-35%. He presented to the emergency department complaining of four days of shortness of breath and paroxysmal nocturnal dyspnea. 
The health plan's determination of medical necessity is upheld in whole. This patient presented with dyspnea and was in decompensated heart failure. He was hemodynamically stable, in sinus rhythm and was not tachypneic or hypoxic. There is no indication in the records provided that there was a significant concern for ischemia. He responded well to intravenous furosemide and was able to be discharged
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Bronchial asthma, past medical history included Asthma, Pneumonia, Bipolar disorder, Polysubstance abuse, Anxiety and Depression.

Treatment: Inpatient admission, diagnostic testing, and medication management

The insurer denied inpatient admission. That denial was upheld.

The patient presented to the Emergency Department with complaints of cough, shortness of breath and sputum production for two days.  Cough was productive of thick yellow sputum.  Vital Signs at presentation were: Temperature 98.5F, respiratory rate 18, blood pressure and  119/75 mm Hg.  Oxygen saturations were 100%.  The patient was in no acute distress.  Lungs were clear.  There were normal breath sounds.  There was no use of accessory muscles.  Cardiac exam was within normal limits.  The patient was alert and oriented x3 with a non-focal neurological exam.

The patient initially received DuoNeb, cough syrup, Motrin, and Doxycycline in the Emergency Department (ED).  Urine toxicology was positive for Cocaine and Opiates.  Peak expiratory flow (PEF) was 200 (baseline was 200LPM)

She was given Azithromycin and Ceftriaxone.  The patient was tolerating a regular diet.  As per the history and physical done at 14:45  the patient was sitting in bed in no acute distress.  The patient remained stable after admission.  The patient was afebrile and hemodynamically stable.  Oxygen saturations were 100% on room air.  The patient was reported to be feeling better.  The Attending Physician discontinued Ceftriaxone. Azithromycin continued.  The steroid was tapered.  The patient was thought to have exacerbation of asthma secondary to bronchitis.

This patient did not need acute hospitalization.  She was afebrile, hemodynamically stable and remained so after admission.  She was not hypoxic.  There was no definite pneumonia in fact CT chest revealed atelectasis without any consolidation.  White blood count (WBC) was normal.  The patient was tolerating oral intake.  Peak expiratory flow (PEF) was at baseline.  CURB 65 score was zero. This patient could have been placed in observation status while diagnostic testing and treatment were initiated.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of sarcoidosis, breast cancer, pulmonary embolism, anxiety, and complex regional pain syndrome and presented to the hospital with a chief complaint of shortness of breath. 

Chest x-ray was negative for acute findings. The patient was admitted for sarcoidosis. The plan of care included intravenous (IV) steroids, bronchodilators, pulmonology consult, cardiology consult, pain management, and continue other home medications. Cardiology saw the patient and requested telemetry and continuation of current medical therapy. Pulmonology recommend a chest computed tomography (CT). The chest CT demonstrated interval mild subpleural reticular changes consistent with inflammatory etiology. Palliative care saw the patient for pain management and compression fracture and adjusted the pain medication. Neurosurgery also saw the patient because of a thoracic vertebral compression fracture and recommended against a surgical intervention. The patient was also started on tizanidine and lidocaine patches for the thoracic compression fracture. A review of the medication history shows that the patient was receiving IV morphine boluses as needed for pain daily through the date of discharge.

The health plan's determination is overturned.

The reason is that while the patient was admitted for a sarcoidosis flare, the patient remained in the hospital because of uncontrolled pain. The patient had a history of complex regional pain syndrome and evidence of a new vertebral fracture and was seen by the pain management service and neurosurgery, and was receiving IV morphine in addition to oral pain medication. Patients with severe pain requiring IV opioid therapy for prolonged periods of time are not typically managed at the outpatient level because of the risk of an adverse event, such as respiratory depression or persistent severe uncontrolled pain.
Appeal type: Medical necessity
Decision: Upheld

This patient  presented to the emergency room (ER) with complaints of back pain and radiation to the right lower abdomen with nausea and vomiting.  The patient reported right sided lower flank pain.  This was not accompanied with pain on urination.  The patient was afebrile at 97.7 degrees Fahrenheit.  The patient had a normal blood pressure of 98/66 and had a normal pulse of 74.  The pain was reported to be acute with a pain score of 10/10.
Patient had no prior medical or obstetrical history reported.  A urine pregnancy test was completed and positive.  The patient's examination was significant for right costovertebral angle tenderness and suprapubic pain without rebound or guarding.  The patient gave a urine sample where 2 small stones were seen in the urine.  A urinalysis was completed and suggestive of urinary tract infection.  The patient was started on Ceftriaxone for urinary tract infection (UTI).  Patient continued to be stable, was on a regular diet, and was hemodynamically stable.  The patient was planned for a course of intravenous (IV) antibiotics for 48 hours.  Inpatient admission was not medically necessary.  This patient was noted to have a diagnosis of nephrolithiasis and urinary tract infection.  The patient was confirmed to have renal stones and passed these in the ER.  The patient was not confirmed to have a urinary tract infection, as she had a negative culture.  Patient was treated empirically with Ceftriaxone and fluids.  The management in this case with a stone that has passed is supportive; the management of symptomatic stones in pregnancy would have ended with the passage of the stones based upon peer reviewed literature and MCG criteria as cited.  The health plan's determination is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache, dizziness, nausea, and vomiting. And EKG changes

Treatment: Inpatient admission, diagnostic evaluation and medication management.

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

The patient has a history of substance abuse, namely crack cocaine. She presented to the Emergency Room (ER) with complaints of headache, dizziness, nausea, and vomiting.  Vital signs noted an initial blood pressure of 125/85 which dropped to 91/61. Her EKG showed normal sinus rhythm with non-specific T wave inversions.  Troponin was negative.  She was admitted despite her symptoms improving after administration of meclizine, Tylenol, famotidine, and magnesium sulfate.  She was evaluated by cardiology who recommended an echocardiogram, however the patient eloped. 

The patient presented with a headache and non-specific EKG changes. However, there were no signs or symptoms of hemodynamic instability, myocardial ischemia, arrhythmia, heart failure, cerebrovascular insufficiency or other organ dysfunction requiring inpatient admission status. There were no findings warranting acute neurosurgical intervention.  The patient's care could have been provided under observational level of care with up to 23 hours of monitoring.  The observational level of care would have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

The patient is diagnosed with autism spectrum disorder. The patient receives home and school-based applied behavioral analysis (ABA) therapy, speech therapy, occupational and physical therapy.

The health plan's determination is upheld. The requested health service/treatment of Personal Care Assistance is not medically necessary for this patient. The patient is already receiving significant developmental intervention. The patient attends school from 7:30-3:00, which should provide the parent with several hours during which he/she can attend to chores and leave the house. The patient also receives center-based and in-home ABA therapy, speech therapy, occupational and physical therapy. The patient does not have any medical issues which might require provision of a personal care assistant.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the hospital for an elective staged percutaneous coronary intervention (PCI). He had a history of diabetes and hypertension. He had previously had a catheterization and was found to have a 70% distal left anterior descending (LAD), 100% first diagonal, 70% circumflex, and 80% posterior descending artery (PDA) which underwent percutaneous coronary intervention (PCI) at that time. The patient was brought in to undergo PCI of the circumflex stenosis which was accomplished without complications. The health plan's determination is upheld. The patient had an elective coronary intervention. It was reasonable to observe the patient for several hours after the procedure to assure that no adverse events occur. However, the expected risk is low and the probability of discharge within 24 hours was very high. As such, the patient could have been monitored at a lower level of care without full admission. An inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease; status post radial artery cardiac catheterization 

Treatment: Inpatient admission 

Summary:
The inpatient level of care was medically unnecessary.
This was a non-urgent, uncomplicated cardiac catheterization with a PCI that was scheduled. Indication was that he had an elective outpatient nuclear test that was positive. No chest pain described, no arrhythmias, no pulmonary edema.  Patient was always hemodynamically stable with normal vital signs, normal EKG, and no ectopy. Only care given after the uncomplicated radial artery catheterization was monitoring, IVF, and routine medications. This care does not require a higher level of care.