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

Diagnosis: Paranoid Schizophrenia 

Treatment: Continued Inpatient Hospital Admission

The insurer denied the Continued Inpatient Hospital Admission. The denial was modified. 

This is a male patient who was admitted to the hospital for inpatient mental health treatment for psychotic symptoms that included hallucinations, disorganized thinking and behavior, paranoid delusional thoughts, suicidal ideation, talking to himself, and poor activities of daily living (ADL). He had a history of schizophrenia and past psychiatric hospitalizations. The patient was started on Zyprexa and Depakote, and he verbalized feelings of improvement. The patient was discharged home with instructions 
to follow up with aftercare.

The APA Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with 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 are candidates for hospitalization. 

Notes reported that his self-care improved, sleep improved, he had brighter affect and was calmed and was not talking to self-according to a note on that date. Two days after admission there were no further reports of significant psychotic symptoms, severe depressive symptoms, homicidal or suicidal ideation, plan or intent, and there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24 hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting.

This reviewer disagrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital from the day of admission and the following day, but agrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital for the days thereafter.

Based on the above, the medical necessity for the continued inpatient hospital admission is not substantiated. The insurer's denial is modified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle Cell Crisis
 
Treatment: Inpatient Admission

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

This is a young male patient who presented to the Emergency Department (ED) by emergency medical serves for severe body pain for three days. He described the pain to be 8/10 in severity. He had been taking morphine elixir, Motrin, and medical marijuana at home in attempts to manage his pain. He has a past medical history of sickle cell anemia, asthma, and a heart murmur. He reported that his last blood transfusion was one year prior to this admission. A chest x-ray was performed which revealed no acute infiltrate or effusion; he tested negative for the flu. Despite the efforts of the ED, the patient was admitted for further pain management. The patient continued to receive hydromorphone and morphine every four hours. The patient expressed improvement in his shoulder pain, however, the pain in his legs continued to persist.  He received Dilaudid and Motrin with documented pain improvement and was then discharged home. 

According to current literature a patient may be admitted to inpatient services when there is evidence of a nervous system injury, acute chest syndrome, hypoxemia or acidosis, acute renal failure, an aplastic crisis, or there is pain insufficiently responsive to observation care treatment requiring treatment in an inpatient setting.  Within the documentation it was noted this patient did attempt oral medication prior to presentation to the hospital.  The patient presented to the emergency department complaining of severe pain.  The patient was given IV medication; however he continued to complain of ongoing severe pain despite administration.  The patient continued to be assessed and throughout the hospital stay he continued to receive IV pain medication and reported unremitting pain.  The documentation detailed the patient was closely monitored and a lower level of care was not appropriate given the failure of oral pain medications to sufficiently control pain from the sickle cell crisis.  

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

Diagnosis: Infertility
Issue under review: Additional cycles of IVF

Determination:
The Additional cycles of IVF are not medically necessary.

The patient is of advanced reproductive age and has a diagnosis of severely diminished ovarian reserve. Four cycles of in vitro fertilization have been performed on the patient. Poor stimulation responses occurred in all cycles despite efforts to increase the stimulation response. These efforts included estrogen priming, testosterone priming and extremely high dose gonadotropin treatment. Low numbers of oocytes were obtained, and consistently poor embryo growth was noted. No embryos were transferred in these cycles. The patient has undergone an adequate amount of cycles to demonstrate and to confirm her poor ovarian reserve and response. Further attempts at IVF treatment with her own oocytes is extremely unlikely to result in embryo transfer, and even less likely for a live birth. Therefore, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
 
Treatment: Inpatient Admission

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

This is a female patient who presented to the Emergency Department with complaints of non-radiating intermittent chest pain that she described to be rated 6/10. She has a past medical/surgical history of hypertension, diabetes mellitus, hysterectomy, and cataract removal. She was consulted by cardiology. She had a computerized tomography and an X-ray of her chest, both tests were negative. Her EKG revealed a normal sinus rhythm with no ischemia. Her laboratory work up and cardiac enzymes were within normal limits. She was discharged and instructed to follow up with cardiology within the next 1-2 weeks.

Many patients admitted to the hospital with cardiorespiratory and other acute syndromes are placed on electrocardiographic monitoring. Such electrocardiographic surveillance theoretically allows the clinical staff to monitor admitted patients for the development of dysrhythmia, both brady- and tachydysrhythmia-in essence, identify patient decompensation and/or clinical deterioration as it occurs rather than after the event. Electrocardiographic monitoring, also known as telemetry monitors or cardiac monitoring focuses on the detection of clinically significant dysrhythmia, rather than the diagnosis of acute coronary syndrome (ACS) or acute pulmonary edema. Although electrocardiographic monitoring (ECGM) has advantages and is undoubtedly invaluable in certain patients, significant overuse of cardiac telemetry monitoring does occur. The impact of this inappropriate use increases the cost of healthcare and can delay the admission process, an unpleasant burden which the hospital and its patients must bear. In addition, the liberal use of monitoring in unnecessary situations may give the hospital staff a false sense of security and/or desensitize them to alarms. In many instances, electrocardiographic monitoring may not be necessary. (5)
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Bleeding from tooth extraction site
 
Treatment:  Inpatient Hospital

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

This patient is a young child who presented to the emergency department with complaints of bleeding and was status post 5 teeth extraction from the previous day.  It was reported that the patient's teeth extractions were due to caries and in preparation for her planned cardiac surgery.  The patient was evaluated by oral surgery who determined that several sutures were needed at the extraction sites; this was performed under local anesthesia. It was reported that the bleeding had stopped after the sutures were placed. She was given oral antibiotics and admitted for observation. She was discharged home the next day.

Upon examination of the medical record, it is noted that aside from the bleeding noted from the extractions sites from the previous day, the patient did not exhibit any distress clinically or based on laboratory values.  She was able to ambulate and did not demonstrate any hematologic abnormalities.  The bleeding was addressed under local anesthesia with primary closure with sutures.  After the procedure, the patient did not exhibit any distress or complications and bleeding ceased.  She was hemodynamically stable and was able to eat and drink without difficulty.  The medical record documentation does not support or substantiate the necessity of an inpatient admission.  This patient could have been discharged from the ED after successful treatment.  The patient does not fulfill the MCG criteria for head and neck acute admission. 

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: Upheld

The patient is a female with a history of hypertension, diabetes, hyperlipidemia, carotid arterial disease and coronary artery disease with coronary artery bypass graft surgery and multiple percutaneous coronary interventions. In early 2019 she was admitted to the hospital with unstable angina. Cardiac catheterization at that time showed occlusion of the bypass grafts to her left anterior descending (LAD) and obtuse marginal arteries. Intervention was performed on the native LAD. Subsequently, she had recurrent chest pain. She presented to the hospital for scheduled, elective cardiac catheterization and planned brachytherapy. Her blood pressure was 160/72 millimeters of mercury (mmHg) with a heart rate of 68 beats/minute. Her physical exam was unremarkable. There is no mention of chest pain upon presentation or dynamic electrocardiographic changes. Complex intervention involving laser atherectomy and brachytherapy to the left anterior descending artery and first diagonal artery was performed. The procedure was uncomplicated. The patient was admitted to the hospital post-procedure. She had an episode of chest pain later in the day that was not associated with any electrocardiographic changes and resolved when her usual dose of ranolazine was administered. She was discharged the following day.

The health plan's determination is upheld.

While some period of monitoring immediately following percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. The 2009 Expert Consensus Document from the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications. Per the recommendations, hemodynamically stable patients without evidence of acute coronary syndrome or dynamic electrocardiographic changes, and whose procedures are uncomplicated, can be monitored overnight but do not require an inpatient admission. Therefore, this patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute dyspnea 
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

The patient's condition improved with emergency room care, and she was on oral prednisone and home dose of supplemental oxygen. The patient was tolerating oral diet and was hemodynamically stable. The acute in hospital level of care was not medically necessary.

Since the patient's condition improved significantly with emergency room care, and the patient was discharged after one day length of stay, the acute inpatient level of care does not meet medical necessity. The observation level of care would have been as effective in this case.
Appeal type: Medical necessity
Decision: Overturned

The patient has history of hypertension, diabetes, and obesity who presented with neck pain and left cervical radiculopathy. The patient did undergo a trial of conservative treatment including oral medications, physical theory and injection therapy with persistent symptoms. A cervical magnetic resonance imaging (MRI) showed C5/6 disc herniation. The patient underwent anterior cervical discectomy and fusion at C5/6. The patient was discharged the following day. The inpatient admission is under review.

The health plan's determination is overturned. The patient underwent anterior cervical discectomy and fusion which requires retraction of the carotid artery and esophagus and trachea. The surgery also involves decompression of the spinal cord and nerves which can impact post-surgical care. Prior to surgery, the complications associated with the details including the carotid artery, esophagus, trachea including potential airway compromise, and spinal cord cannot be predicted and require overnight admission to monitor and potentially treat any of those complications directly related to surgery. These complications can result in death and should be treated immediately. The inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left temporal parietal stroke with spastic hemiparesis of the right side
 
Treatment: Occupational Therapy

The insurer denied additional occupational therapy treatment. The denial was reversed.

This is a male with a left temporal parietal stroke 2 years ago. A recent examination noted that the patient was seen for spastic hemiparesis of the right dominant side due to cerebral infarction. The patient had impaired activities of daily living and required assistance when transferring to the shower chair. There was trace movement throughout the right upper extremity. Strength was normal except the right upper extremity which was 1/5. There was weakness noted in the ankle on the right and he required an AFO for stability. There was spasticity to the right upper extremity. A treatment note indicated the patient was seen for occupational therapy. The patient had decreased dexterity, strength and tone. He met the goal of transferring to shower chair and showering independently. He had increased finger and wrist tone. The patient required moderate verbal cueing to avoid compensatory trunk movement. He required assistance to abduct thumb to achieve pincer grasp and then assistance with tenodesis to drop block into a container. The patient was to continue with therapy 2 times per week for 11 weeks.

The medical literature notes that extended occupational therapy (OT) may be indicated when  functional progress has been made during initial therapy, or the patient requires maintenance therapy to prevent further deterioration, and goals of therapy are not yet met but the patient is actively participating in the treatment and is adherent to the plan of care. This patient previously completed at least 10 OT visits. The patient was noted to have made improvement with past OT but continued to have deficits on examination. The 4 additional occupational therapy visits are medically necessary.

Based on the above, the medical necessity for 4 additional occupational therapy visits is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's disease, B12 deficiency-on supplements

Treatment: Enteral Therapy (Boost)

The insurer denied coverage for Enteral Therapy (Boost). The denial was upheld.

This patient is a female with Crohn's disease on multiple medications, other specified hypothyroidism-Euthyroid, mild aortic stenosis-asymptomatic, chronic venous insufficiency-stable, narcotic dependence-being weaned off, B12 deficiency-on supplements, tobacco abuse-active smoker, and dysuria-mild.  It was noted that she was losing weight due to poor appetite.  It was also noted that the patient was keen about not returning to a prior morbid obese state and was actively eating less.  Per a Uniform Assessment System (UAS)-New York Comprehensive Community Assessment Report the patient required maximum assistance with meal preparation and other functional tasks and required diet modification to swallow solid food as she reported a soft diet and difficulty swallowing because of a history of thyroid disease.  The patient also had top and bottom dentures.   

The patient had Crohn's disease and was losing weight due to poor appetite. She was able to eat but wanted to take nutritional supplements. Her BMI is reported to be 21.97.

An Up-To-Date article titled "Nutrition and dietary management for adults with inflammatory bowel disease" states that we do not use supplemental nutrition as primary maintenance therapy for patients with Crohn's disease. Efficacy studies have either been inconclusive or have yielded mixed results.

An Up-To-Date article titled "Obesity in adults: Prevalance, screening and evaluation" states that the National Institutes of Health and the World Health organization have developed recommended BMI classifications. Underweight is defined as a BMI < 18.5. Normal weight is defined as a BMI between 18.5 and 24.9. In this case, the patient is classified as having normal weight.

This patient has Crohn's Disease. However, she is able to tolerate a diet. The medical literature has not shown that supplemental nutrition will be beneficial as a treatment for Crohn's disease. The patient also does not fall into the category of being underweight as her BMI is over 18.5. Therefore, the healthcare plan acted reasonably and with sound medical judgment. Enteral therapy is not medically necessary for this patient. 

Based on the above, the medical necessity for Enteral Therapy (Boost) is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right upper quadrant pain
Treatment: Inpatient admission

The inpatient admission was not medically necessary. 

The patient presented with typical signs and symptoms of acute cholecystitis. Work-up and diagnostic imaging were confirmatory. The patient underwent the appropriate surgical procedure without any untoward events and recovered as expected. 

After an uncomplicated elective laparoscopic cholecystectomy, patients can drink clear liquids once awake from anesthesia, and their diet can be advanced as tolerated. Most otherwise healthy, reliable patients with good home support can leave the hospital within six hours after surgery. Cochrane reviews have found no significant differences for important clinical outcomes for patients discharged the same day versus admitted overnight following laparoscopic cholecystectomy. 

A retrospective review of the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) database, which included 15,248 patients older than 65 years of age who underwent elective laparoscopic cholecystectomy, identified congestive heart failure, American Society of Anesthesiologists class-four, bleeding disorder, and renal failure requiring dialysis as significant independent predictors of inpatient admission and mortality.

The patient was admitted, medically managed appropriately, and recovered as expected after surgical intervention. The patient underwent the appropriate surgical procedure without any untoward events and recovered as expected. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
 
Treatment: Inpatient admission, monitoring

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

This is a female with a history of seizure disorder who presented to the ER with abdominal pain. She denied nausea, vomiting or diarrhea.  The pain increased with inspiration and was now localized to the right upper quadrant (RUQ).  Exam revealed RUQ pain to palpation with positive Murphy sign; no rebound or guarding noted. A white blood cell (WBC) count was 14.75. Ultrasound of the abdomen revealed a complex appearing cystic lesion in the liver.  Cholelithiasis was also noted with normal gall bladder thickness and no pericholecystic fluid. The common bile duct was within normal limits. CT of the abdomen revealed a 6.3 x 4.3 x 3.8 cyst, most likely reflective of hydatid disease.  The patient was admitted with abdominal pain.  

According to MCG Inpatient and Surgical Care 23rd Ed. Abdominal Pain, Undiagnosed ORG: M-05 (ISC), admission may be indicated for 1 or more of the following: surgery needed that cannot be performed on ambulatory basis; peritoneal signs present;  evaluation requiring patient to not eat or drink for extended period; hemodynamic instability; severe pain requiring acute inpatient management; identification of etiology or finding that requires inpatient care; signs of intestinal obstruction; suspected toxic megacolon; bacteremia; severe electrolyte abnormalities requiring inpatient care; inability to maintain oral hydration that persists after ED and observation treatment; percutaneous or open drainage procedures; parenteral nutrition regimen that must be implemented on inpatient basis; other condition, treatment, or monitoring requiring inpatient admission.  This patient could have been treated on an observation status and discharged after a 23-hour stay as there was no acute event that required acute care.  The patient did not have acute cholecystitis or obstruction. The CT scan of the abdomen revealed a cyst, which was consistent with a hydatid cyst. 

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