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

Central Nervous System/Neuromuscular Disorder - Other
Inpatient Hospital

The patient is a male with a past medical history significant for anxiety and acid reflux who presented to the emergency department after he sustained a syncopal episode at home. He reported some nonspecific chest discomfort that he experienced before going to bed. Reportedly, he woke up in the middle of the night and walked to the bathroom. Suddenly, he started to feel dizzy and passed out. He woke up on the bathroom floor and was unsure how long he had remained unconscious. He reported a similar episode that occurred five years prior.
At the time of the initial evaluation, the patient was afebrile, blood pressure was 119/63, respiratory rate 16, pulse rate 59, oxygen saturation 100%. The patient was not in acute distress. head, eyes, ears, nose, throat (HEENT) exam was unremarkable. It was mentioned in the history and physical (H&P) note that the patient had a fullness in the neck without thyromegaly or enlarged lymph nodes.
The patient was admitted to the hospital with a diagnosis of syncope, neck fullness and gastroesophageal reflux disease (GERD). Telemetry monitoring was implemented. During the hospital stay the patient underwent an echocardiogram that demonstrated normal left ventricular ejection fraction. There were no clinically significant abnormalities reported.
It was also mentioned that the patient's chest x-ray and ultrasound of the soft tissues of the neck did not reveal clinically significant abnormalities. It was concluded that the patient's syncopal episode was likely vasovagal and the patient's chest discomfort could have been related to GERD. The patient was discharged home in stable clinical condition.

The health plan's determination is upheld.

Following a review of the medical records and using the San Francisco Syncope Rule, admission at the acute inpatient level of care was not medically necessary. The San Francisco Syncope Rule is a risk stratification tool that predicts risk for serious outcomes at 7 days in patients presenting with syncope or near syncope. Based on the calculations, this patient received zero points, therefore he belonged to the low group for a serious outcome. In general, patients with a low risk of serious outcomes could be discharged from the emergency department.
However, clinician judgment should prevail, even if patients are deemed low risk by the San Francisco Syncope Rule. If there was a significant concern for a serious underlying cause of the patient's syncope, workup should be expanded. Taking into consideration the patient's family history of the sudden death of two family members, admission at a lower level of care was definitely appropriate for telemetry monitoring and to rule out acute coronary syndrome.
Admission at the acute inpatient level of care was not medically necessary, considering clinical stability and lack of alarming features noted on the physical exam, in laboratory studies, and on diagnostic tests.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heme positive stools:
Issue under review: Capsule endoscopy

Determination:
The Capsule endoscopy is not medically necessary.

The patient has heme positive stools, which could very well be due to grade II hemorrhoids he has or from diverticulosis. Even though he has heme positive stools, his blood loss is not clinically significant, as his Hb/HCT are normal. On iron panel, even though his iron saturation is low, serum ferritin levels are normal. 

Suspected small bowel bleeding must be significant, as demonstrated by the following criteria: An acute drop in hemoglobin/hematocrit; or unexplained recurrent or persistent iron deficiency anemia; or persistently positive fecal occult blood test; or visible bleeding with no bleeding source found at original upper or lower endoscopy. In this case, there is no follow-up CBC (complete blood count) available to see if there is any significant drop in his Hb/HCT over a period of time, or if the repeat iron studies showed in drop in ferritin or iron saturation. As ferritin correlates well with total body iron stores, and is a better marker of iron deficiency, normal ferritin level in this case rules out clinically significant iron deficiency anemia. Therefore, at this point, capsule endoscopy is not appropriate and medically necessary for evaluation of small bowel as the source of blood loss, which has not clinically manifested with persistent iron deficiency anemia and heme positive stools.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who was a former smoker with a medical history of diabetes mellitus, atrial fibrillation, chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD) and pulmonary hypertension on 2 liters per minute of supplemental oxygen at night and as needed during the day. She was admitted for a diagnosis of pneumonia. She presented with symptoms of a fever, a non-productive cough associated with chest pain, myalgias and fatigue for 1 day prior to admission. The health plan's determination is upheld.
This is a patient with a medical history of diabetes mellitus, atrial fibrillation, chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD) and pulmonary hypertension on 2 liters per minute supplemental oxygen at night and as needed during the day. The patient was hemodynamically stable, her oxygen saturation was reported greater than (>) 91% on her home prescribed dose of 2 liters per minute. She was weaned off oxygen to room air within 24 hours, she was not in any respiratory distress and did not have a respiratory rate greater than or equal to than 30.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: Inpatient admission, diagnostic evaluation, medication management.

The insurer denied inpatient admission. That denial was upheld.


The patient had a history of a gastric bypass and presented with nausea, vomiting, and diarrhea. In the Emergency Room (ER), she had a blood pressure of 85/52 with a pulse of 114 and a temperature of 101.1. By the time of admission, the blood pressure was 101/61 with a pulse of 87 and a temperature of 98.4. There was no abdominal rebound or guarding. The white blood cell count was 8.3. A CAT scan showed enteritis, IV fluids, and IV antibiotics were given. The following day she was tolerating a regular diet.

MCG clinical indications for admission for gastroenteritis (M-170) include having a suspected severe infection such as bloody diarrhea, severe abdominal tenderness, toxic megacolon, severe vomiting, and hemodynamic instability such as tachycardia or hypotension that persists despite treatment. The patient did not meet these criteria the hypotension and tachycardia resolved with IV fluids in the ER.

This patient had gastroenteritis. IV hydration and anti-emetics were given and the patient improved, this treatment could have been given with observation status. Afterwards the antibiotics could have been given orally as an outpatient. The patient did not meet MCG criteria for admission for gastroenteritis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient had mild asthma exacerbation, which improved with emergency room care. The patient was hemodynamically stable at the time of admission. The patient was able to take oral medications. Since the patient's asthma exacerbation symptoms improved with Emergency room care, the acute in hospital level of care was not medically necessary. The observation level of care would have been more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: GHD
Treatment: Humatrope
The Humatrope is not medically necessary.

The peer reviewed literature including consensus clinical guidelines, randomized controlled trials are summarized below:

Classic GH Deficiency:
Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society(1), the Lawson Wilkins Pediatric Endocrinology Society(2, 3), and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists (4). The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on auxological, biochemical and sometimes radiological findings. The auxological criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3.0 SD below the mean; 2) height more than 1.5 SD below the midparental height; 3) height more than 2.0 SD below the mean and a height velocity over one year more than 1.0 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over one year in children over two years of age; 4) in the absence of short stature, a height velocity more than 2.0 SD below the mean over one year or more than 1.5 SD sustained over two years. The biochemical criteria include low insulin-like growth factor one (IGF1) or insulin-like growth factor binding protein three (IGFBP3) or GH stimulation testing with a peak GH less than ten nanograms per milliliter (ng/ml).

The patient did not meet auxological criteria as pretreatment height and height velocity are normal.  This patient met biochemical criteria. GH stimulation testing peaked at less than ten ng/ml.  The Pediatric Endocrine Society recommends against making a diagnosis of growth hormone deficiency based solely on failed growth hormone stimulation testing.

Idiopathic Short Stature:
Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines (4-9). Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS 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 pretreatment height less than or equal to -2.25 SD. The patient therefore does not meet idiopathic short stature criteria. 

The request does not meet any nationally accepted criteria for use of growth hormone. The request is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient  with Type 1 diabetes mellitus (DM), hypothyroidism due to Hashimoto thyroiditis, and short stature, receiving growth hormone (GH) therapy. A review of the growth chart shows that her height decelerated. Her weight similarly drifted from the 50-75th percentile to the 50th percentile over the same time period.  The health plan's determination of medical necessity is upheld in whole.
The patient's pre-treatment height was not more than 2 standard deviations (SDs) below the mean for age and gender, her IGF-1 level was normal, bone age was appropriate for chronological age, and there are no known morphological abnormalities of her pituitary gland to suggest hypopituitarism. She is expected to have been past the peak of her pubertal growth spurt, after which time it is normal for statural growth to slow down.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right Parapharyngeal Abscess
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was reversed.  
This is a female patient who was transferred from another facility for the management of a Parapharyngeal abscess that measure 2.4 x 1.5 x 3 cm. It was reported the patient was experiencing pain, difficulty swallowing and breathing. She had a temperature of 101.8. She was consulted by Ear Nose and Throat (ENT) for the treatment of the abscess. She was treated with antibiotics and intravenous (IV) dexamethasone. She was stabilized and discharged home without surgical intervention. 
The Milliman Care Guidelines indicate that admission to the hospital is appropriate for any abscess or swelling causing significant swallowing difficulty or airway obstruction or partial obstruction. 

This case involves a patient transferred for the management of a large right parapharyngeal abscess measuring 2.4 x 1.5 x 3 cm. The patient reported throat pain, difficulty swallowing, and difficulty breathing. The provider was concerned due to deep neck space infections often have a rapid onset and can progress to life-threatening complications, primarily airway obstruction. Thus, clinicians must be aware of such infections and should not underestimate their potential extent or severity. Non-surgical intervention is an option but requires very close observation due to the need for airway intervention if required.  If there is any indication of an airway compromise the patient should be observed in an ICU setting so that a rapid response could be achieved. 

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

The carrier's denial of coverage for the inpatient hospital services is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

The patient ran 2.5 miles to a gym, and then while exercising became dizzy and suffered a syncopal episode. The patient had not had anything to eat or drink prior to going to the gym. Blood pressure was noted to be 50/systolic. Glucose was 122. The patient received 500 cubic centimeters (cc) of intravenous (IV) normal saline (NS) and was brought to the hospital by paramedics. In the emergency room (ER), BP was 91/52 millimeters of mercury (mmHg) and pulse 71 beats per minute (bpm). Electrocardiogram (EKG) showed sinus bradycardia at 57 bpm. Troponin was 0. Hemoglobin (Hgb) was 14. White blood cell (WBC) count was 8.8. Head computed tomography (CT) showed no acute intracranial process. The patient was admitted overnight and remained stable. The patient was seen in cardiology consultation and ruled out for acute coronary syndrome. Outpatient echocardiogram (ECHO) and monitoring were recommended. The patient also underwent neurology consultation. Electroencephalogram (EEG) was negative. It was not felt that the patient had a seizure. The health plan's determination is upheld.

Inpatient admission is not medically necessary. The patient presented with syncope in the setting of hypotension, likely due to intravascular volume depletion or possibly a vasovagal response. The patient was hypotensive in the field, but BP normalized after intravenous fluids given by paramedics. Evaluation in the ER did not reveal any acute cardiac or pulmonary process, such as acute myocardial infarction (MI), arrhythmia, or pulmonary embolus, or neurologic process, such as cerebrovascular accident (CVA). The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post colectomy/colostomy for perforated diverticulitis with nausea, abdominal pain and fever for 24 hours

Treatment:  Inpatient hospital stay

Summary:
Inpatient admission was not required for this patient. There was no evidence of hemodynamic instability or sepsis, both HIDA and CT scan confirmed a non-surgical problem, and symptomatology resolved rapidly with appropriate medical therapy. Treatment and appropriate medical care could have been performed at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: UTI
Issue under review: Inpatient admission

Determination:
The inpatient admission was medically necessary.

The patient was found to be unresponsive and apneic after a near-fatal suicide attempt. He was treated for a UTI associated with renal dysfunction.  His initial treatment was complicated by an allergic reaction and change in IV antibiotics.  This scenario is in no way a simple case of cystitis or pyelonephritis than can be treated as an outpatient, as stated by the Infectious Diseases Society of America (1).  Furthermore, the suicide attempt required hospitalization and stabilization of medical conditions that could not be done as an outpatient.  Standard of care would require admission of such a patient. Failure to admit such as a patient can lead to death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Flank pain, kidney stone in the setting of pregnancy

Treatment: Inpatient admission, cystoscopy, monitoring

The insurer denied inpatient admission. That denial was upheld

This patient presented to the Labor/Delivery Suite at 21.4 weeks gestation with complaints of worsening left flank pain. The patient had been seen in the emergency room (ER) 2 days prior for the same complaint and was diagnosed with nephrolithiasis. WBC 14.070. The patient was started on intravenous (IV) fluids.  Fetal monitoring was reassuring. The patient was taken to the operating room (OR) by urology for cystoscopy and left stent placement. The patient was unable to void post procedure; bladder scan revealed 800mls urine in the bladder. The patient was to have a Foley placed but voided 600m/s of blood tinged urine, just prior to that. The patient was admitted to labor/ delivery. IV fluids were continued, urine output was monitored.  The patient was discharged home in stable condition. 

Per MCG Health (22nd) Renal Colic + Kidney Stones, the patient fails to meet clinical indications for admission to inpatient care. There was no hemodynamic instability, acute renal failure, bilateral obstruction, transplanted kidney with obstruction. 

Per MCG Health (22nd) Urologic Surgery or Procedure GRG, the patient is noted to have met the general recovery course discharged parameter within 24hour post-operatively - the patient had transient urine retention, but was able to successfully void. As per the guideline, this procedure cystoscopy/stent insertion is normally designated for the ambulatory surgery setting. The patient could have been managed at the observation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COPD (chronic obstructive pulmonary disease)
Issue under review: Inpatient admission
The Inpatient admission was medically necessary.

Summary:
The patient is a male with history of colon cancer on chemo, recent discharge from hospital with sepsis, pneumonia, and pulmonary embolism. He presented to emergency room with worsening shortness of breath (SOB) and diarrhea, as well as chronic pain. 

The patient was initially admitted to observation care with COPD exacerbation and was started on IV steroids and nebulization, as well as supplemental oxygen. However, the patient failed observation care and continued to have SOB/DOE (dyspnea on exertion), fatigue and diarrhea, as well as pain. The patient also had failure to thrive with unsteady gait requiring physical therapy prior to discharge.  Thus, the acute inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

The patient has short stature and delayed puberty. Height has been tracking at or below the 1st percentile and weight along the 25th percentile. The patient is a former 30-week premature infant, one of a twin gestation, born with a birth weight of 2'11", status post hernia repair. Mid-parental target height is 64 +/- 2 inches.

At presentation to a pediatric endocrinologist in 5/17, the patient was growing at a normal growth velocity for age. Height was 138.2 centimeter (cm) (standard deviation score [SDS] -2.7) and weight was 38.8 kg (SDS -1.18). The patient was pre-pubertal, and bone age was 11 6/12 years. Insulin-like growth factor 1 (IGF-1) level was 219 nanograms per milliliter (ng/mL), complete blood count (CBC), erythrocyte sedimentation rate (ESR), comprehensive metabolic panel (CMP), prolactin, and celiac screen were all negative. Provocative growth hormone (GH) testing in 9/17 revealed a peak GH response of 13 ng/mL normal. Magnetic resonance imaging (MRI) of the brain was normal.
The health plan's determination is overturned. 

While the patient had a normal screening IGF-1 level and normal results on provocative GH testing, the pre-treatment height was 3 standard deviations (SDs) below the mean for age and gender, and he had a persistently poor growth velocity, raising concern that the patient would not reach growth potential.

According to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than 2 SD below the mid-parental height percentile; (2) growth velocity less than (<) 25th percentile for bone age; (3) bone age more than 2 SD below the mean for age; (4) low serum IGF-1 and/or insulin-like growth factor binding protein-3 (IGFBP-3); and/or (5) other clinical features suggestive of GH deficiency. This patient meets most of the above criteria. Thus, a trial of GH therapy is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Decision: Slurred speech, past history to include hypertension as well as lymphoma, myocardial infarction with stent, and depression

Treatment: Inpatient admission, diagnostic testing, medication management.

The insurer denied inpatient admission. That denial was upheld.

This patient presented to the emergency department for 1 week of slurred speech.  The patient had trouble getting his words out.  The patient also endorsed feeling lightheaded with decreased balance.  Upon physical exam the patient was in no acute distress.  The documentation in the emergency department (ED) indicated abnormal findings for finger-to-nose, there was slurred speech and decreased sensation to the left side of the face. Subsequent Neurology consult notes indicated the patient's speech was guttural/slurred, left sided sensation was inconsistent and changed from initially normal to slightly decreased, ambulation was normal with slightly wide based gait.  It was recommended that the patient undergo multiple laboratory and diagnostic studies.  The CT scan of the head did not reveal any evidence for intracranial hemorrhage, mass or extra-axial collection. The CT angiography revealed no evidence of intracranial large vessel occlusion, aneurysm or vascular malformation.  There was possible moderate to severe stenosis at the origin of the left vertebral artery.  The patient was admitted for a stroke work-up.  The patient was treated with aspirin and seen by neurology.  It was recommended that the patient undergo an MRI and consider a psychiatric evaluation and/or a toxicology screen regarding adverse effects of Lexapro.  The patient was to undergo genetic testing for spino-cerebellar ataxia, Fredericks ataxia or Wilson's disease as an outpatient.

According to the referenced literature a patient may be admitted to an inpatient status when there is evidence of vasculitis, a severe CNS infection, cerebral aneurysm or there is evidence of a new onset severe neurologic finding that requires inpatient care.  Within the documentation, the above was not noted.  It was noted that this patient was seen complaining of slurred speech.  The imaging and laboratory studies did not indicate the patient had any type of acute pathology that would meet the above indication.  The documentation also did not indicate that the patient had any findings warranting the need for inpatient services versus observation.