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

Diagnosis: Seizures
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The differential diagnosis of first-time afebrile seizure activity is quite broad, and includes head trauma, abuse, toxic ingestion (intentional or accidental), infection, elevated intracranial pressure, and anatomic abnormalities. Initial evaluation must include a complete history and comprehensive physical examination to identify possible life threatening causes of seizures. Characterization of the type of seizure is also important, differentiating between febrile and afebrile, focal and generalized. "After the initial acute investigation, which often includes metabolic and CT scanning, depending on the clinical presentation in emergency room, in a child with a first nonfebrile seizure, it is recommended to obtain an EEG to help predict the risk of seizure recurrence. Subsequent imaging studies with MRI should be seriously considered in any child with a significant cognitive or motor impairment of unknown etiology, unexplained abnormalities on neurologic or psychiatric examination, a seizure of focal onset with or without secondary generalization, an EEG that does not represent a benign partial epilepsy of childhood or primary generalized epilepsy, or in children younger than 1 year of age. Other laboratory tests or lumbar punctures may be pursued depending on the specific clinical settings." (1) Medication may or may not be necessary depending on the clinical presentation. Risk for seizure recurrence is greatest within the first six months. (2)

This male infant presented to the ED after having multiple brief episodes of self-resolved stiffening, with no loss of consciousness, no post-ictal period, no loss of bowel/bladder, and no alteration in mental status. He had no fever upon presentation, but spiked fever during his time in the hospital. While it was not unreasonable to monitor this infant in the hospital for further spells and obtain video EEG monitoring, he was overall hemodynamically stable with no cardiorespiratory compromise and no neurologic deficit. He did not require acute inpatient management, and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient presented for an elective percutaneous coronary intervention (PCI) based on a diagnostic catheterization. The patient had a history of hypertension, hyperlipidemia, diabetes, systolic heart failure, and previous bypass surgery (left internal mammary artery (LIMA) To left anterior descending (LAD) for high grade stenosis). The patient underwent successful drug eluting stenting of the posterior descending artery (80% pre, 0% post-PCI) and posterolateral branch (90% pre, 0% post PCI). The patient was observed uneventfully overnight and discharged. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient had an elective coronary intervention. It is reasonable and appropriate to monitor the patient for several hours after the procedure. However, it was very likely that the patient would be ready for discharge within 8-23 hours after the procedure. Thus, the patient could have been observed at a lower level of care without the need for full admission. Thus, the inpatient stay was not indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fluid overload
 
Treatment: Inpatient Admission

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

This is a male patient who presented to the hospital with complaints of shortness of breath and a cough. He had a history of diabetes, hyperlipidemia, hypertension, and end stage renal disease and is on hemodialysis. On evaluation in the emergency department the patient was noted to have diminished breath sounds at his lung bases with rales. His oxygen saturation was 98% on room air. He had a chest x-ray that revealed mild pulmonary congestion. A laboratory work up was done which revealed an elevated troponin and brain natriuretic peptide (BNP). Nephrology consulted on the patient. It was determined that the patient was in fluid overload; he received intravenous Lasix and was scheduled for hemodialysis later that day. The patient responded well to the treatments, and was discharged home the following day when he was medically stable. 

According to the referenced literature a patient may be admitted to inpatient services when there is evidence of hemodynamic instability, severe electrolyte abnormality, cardiac arrhythmias of immediate concern, when there is evidence of precipitating causes for acute decompensation requiring inpatient care, acute cardiac ischemia causing or associated with failure, pulmonary edema that is persistent, tachypnea, dyspnea, altered mental status, increased creatinine, acute renal failure, or acute peripheral ischemia. Within the documentation it was noted the patient presented with complaints of coughing and shortness of breath. The patient was dialyzed with improvement and subsequently discharged the following day. 

Based on the above, the medical necessity for the Inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Hypertension/High Blood Pressure
Inpatient Hospital

The patient is a male with a history of hypertension and chronic kidney disease. He was referred to the emergency department from an urgent care center for marked hypertension. He had gone to the urgent care clinic complaining of a painful right foot wound and bilateral lower extremity edema. He had been noncompliant with his antihypertensive regimen. During transport his blood pressure was 212/130 millimeters of mercury (mmHg) with a heart rate of 82 beats/minute. In the emergency department it was 241/140 mmHg. His physical exam was remarkable for bilateral lower extremity edema and a 2X4 centimeter (cm) blister on the sole of the right foot. His electrocardiogram showed no acute changes. His serum creatinine level was 2.38 milligrams per deciliter (mg/dl) (baseline 1.9 mg/dl). His serum troponin level was mildly elevated. His N-terminal pro brain natriuretic peptide (BNP) level was mildly elevated for his age. He was treated with his usual home antihypertensive medications which resulted in a 25% drop in his blood pressure. He was then admitted to the hospital with a diagnosis of hypertensive urgency. At the time of admission his blood pressure was 156/74 mmHg. His diuretic was held due to the increase in his serum creatinine level. The following morning his blood pressures were in the 130s/80s mmHg range. His creatinine level was 2.08 mg/dl. He was discharged home.

The health plan's determination is upheld.

This patient presented with uncontrolled hypertension due to noncompliance with his medical regimen. His blood pressure responded promptly to treatment with his usual oral antihypertensive medications. There was no evidence of acute neurologic complications or decompensated heart failure. While his serum creatinine level was increased compared to his baseline level, urinalysis was not consistent with renal damage due to malignant hypertension. The following morning his level had decreased to near his baseline. His serum troponin level was mildly elevated; however, the records do not indicate that there was suspicion for acute coronary syndrome. The elevation was likely due to his renal disease and/or increased myocardial demand due to his marked hypertension.

There is no evidence that rapid lowering of blood pressure in asymptomatic patients with severe hypertension, without acute end-organ damage is of benefit and, in fact, it can be harmful. Outpatient titration of antihypertensive medications with lowering of blood pressure to goal over a period of weeks has been shown to be both safe and effective. Given this patient's elevated troponin level and increased serum creatinine, he could have been managed at a lower level of care. However, an inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Ataxia/Inability to coordinate voluntary muscular movements
Inpatient Hospital

The patient is a man with history of hypertension, coronary artery disease (CAD), diabetes, peripheral vascular disease, and end-stage kidney disease who was admitted from the emergency department. He presented with a chief complaint of syncope. He reported that he was feeling lightheaded over the past few months and his symptoms had worsened. He stated that his dizziness was associated with nausea. He also reported shortness of breath. He denied fevers and chills. Recent history was notable for missing dialysis. Vital signs in the emergency department showed temperature 97.7 Fahrenheit, blood pressure 96/61, and respiratory rate 18. On physical examination, heart was regular, breath sounds were normal, cranial nerves were intact, and there were no neurologic deficits. Labs showed sodium 137, potassium 4.9, glucose 118, Magnesium 2.7, and troponin negative. Head computed tomography (CT) was negative. The patient was admitted for syncope. The plan of care included intravenous (IV) fluids, monitor blood pressure, cardiology consult, gastroenterology consult for chronic diarrhea, physical therapy consult, stool studies, renal consult, dialysis as needed, and continue other home medications. He remained stable during the hospital stay with no recurrent episodes of syncope. Cardiology noted that an invasive cardiac catheter was already scheduled and gastroenterology recommended further management as an outpatient. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient was hemodynamically stable, labs were stable with no abnormalities requiring acute treatment, and there was no imaging evidence of acute stroke or acute hemorrhage or mass effect. There was no evidence of acute cardiac arrhythmia, acute seizure, encephalopathy or meningitis or other acute infection. His syncope required further evaluation but could have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
 
Treatment: Continued Inpatient Detoxification Services

The insurer denied the Continued Inpatient Detoxification Services. The denial was reversed. 

This is a male patient who presented to a rehabilitation facility for detoxification for multiple substances. He had withdrawal symptoms that included tremors, joint pain, sweats, runny nose, irritability, anxiety and elevated heart rate of 108. He had a Clinical Opiate Withdrawal Scale (COWS) of 14 and a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) of 2. He has a history of drinking 1 pint of alcohol per day, using multiple bags of intravenous (IV) heroin and IV cocaine daily, smoking multiple bags of methamphetamine, smoking blunts of cannabis, and using 80 mg of Methadone. He also had a history of inpatient substance detoxification. He was treated with a Methadone protocol and was discharged to substance inpatient rehabilitation when medically indicated.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. 

According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use substances despite past inpatient substance detoxification treatment and negative consequences including legal problems, and he needed two detoxification medications to modify withdrawal and prevent severe, complicated, and life threatening withdrawal as he took Librium and took Methadone. He still had withdrawal symptoms reported including tremors and anxiety and still required Methadone detoxification medication. Also, the risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required the entire time. It also was necessary to get detoxification treatment prior to inpatient substance rehabilitation treatment and he could not successfully be detoxified in an outpatient setting.

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

The patient has diabetes, diabetic neuropathy, hypertension, and hyperlipidemia. Per the appeal letter, the patient had tried pravastatin and Zetia without adequate low density lipoprotein (LDL) lowering. The patient had a history of elevation of liver function tests, alanine aminotransferase (ALT) 65 and aspartate aminotransferase (AST) 37 off statin. ALT was up to 118 and AST 54 while on pravastatin. Repatha was prescribed and is under review.

The health plan's determination is upheld. Repatha is not medically necessary for this patient. The patient has an elevated LDL and could not take pravastatin. The patient does not meet indications for evolocumab (Repatha), a PCSK 9 inhibitor. The patient does not have familial hypercholesterolemia. Also, the patient does not have established, clinical cardiovascular disease. The patinet has minimal carotid atherosclerosis (0-19% based on the ultrasound), but no clinical evidence for atherosclerotic cardiovascular disease, such as angina, claudication, transient ischemic attack (TIA) or cerebrovascular accident (CVA).
Appeal type: Medical necessity
Decision: Upheld

Diganosis:  GERD
Issue under review:  LINX procedure

Determination:  The LINX procedure is not medically necessary.

LINX is not proven therapy in this case based on published literature.  LINX is not known to be health beneficial for this patient's condition of GERD in the setting of prior roux-en-Y gastric bypass and reported Barrett's metaplasia of the distal esophagus.

While LINX magnetic sphincter augmentation has been shown by scientific evidence to be safe and effective for the condition of GERD with proven elevated esophageal acid exposure, preserved motility and no alternative diagnosis, in this case the records indicate a history of prior gastric surgery and Barrett's metaplasia.

General precautions listed by the manufacturer for LINX implantation include a diagnosis of Barrett's, as the safety and effectiveness of the LINX device has not been evaluated in patients with Barrett's esophagus or Grade C or D (LA classification) esophagitis.  This patient has a history of prior roux-en-Y gastric bypass and Barrett's, as detailed in the EGD (esophagogastroduodenoscopy) report, the UGI report, and surgical H&P (history and physical).    

Other precautions (per the manufacturer) to LINX implant where the safety and effectiveness of the LINX Reflux Management System has not been established include:
 - Scleroderma
 - Suspected or confirmed esophageal or gastric cancer
 - Prior esophageal or gastric surgery or endoscopic intervention
 - Distal esophageal motility less than 35 mmHg peristaltic amplitude on wet swallows or <70% (propulsive) peristaltic sequences or High Resolution Manometry equivalent, and/or a known motility disorder such as Achalasia, Nutcracker Esophagus, and Diffuse Esophageal Spasm or Hypertensive LES
 - Symptoms of dysphagia more than once per week within the last 3 months
 - Esophageal stricture or gross esophageal anatomic abnormalities (obstructive lesions, etc.)
 - Esophageal or gastric varices
 - Lactating, pregnant or plan to become pregnant
 - Morbid obesity (BMI >35)
 - Age < 21

This patient has undergone prior roux-en-Y gastric bypass, and she has Barrett's metaplasia, per recent upper endoscopy.  For these reasons, the proposed LINX is not known to be beneficial and would be considered unproven and not medically necessary.  There is no published literature to support the efficacy of LINX in the setting of prior gastric bypass surgery.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment: inpatient hospital admission

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

This patient is a male, who was seen in the emergency department. The patient had complaints of abdominal pain. The patient had a temperature of 98.1F with a heart rate of 71, respirations 20, oxygen saturation 98% and blood pressure 103/65.  The pain level was a 6/10. The patient stated he had diffuse abdominal pain x3 days with nausea and poor appetite.  The patient had a past medical history of lap band. Examination showed tenderness to the abdomen. The patient had glucose of 105, the blood urea nitrogen (BUN) 18, creatinine 1.1, sodium 142, potassium 4, chloride 111, carbon dioxide (CO2) 26, calcium 9.4 protein 6.4. The white blood cell (WBC) count was 8.53 K, red blood cell count 4.54, hemoglobin 14, hematocrit 40.3, platelets 266. A Computer Tomogram (CT) showed a 2 mm non-obstructing right renal calculus. The appendix was at the upper limits of normal and there was possible slight surrounding fatty infiltration which could represent early acute appendicitis. A repeat CT revealed minimally dilated appendix with trace adjacent inflammatory changes. The patient then underwent the laparoscopic appendectomy and cholecystectomy. The patient was stable following surgery. The patient was discharged in stable condition.

The medical literature indicates that the goal length of stay following a laparoscopic appendectomy without peritonitis is ambulatory. An extended stay beyond the goal length of stay may be indicated for patients with complicated appendicitis, complications following surgery such as wound infection, wound dehiscence or enterocutaneous fistula, continued ileus or postoperative bleeding issues. The goal length of stay for cholecystectomy is considered ambulatory. The documentation indicated that the patient did have findings of appendicitis. The patient underwent a laparoscopic appendectomy and cholecystectomy. There was no evidence of complicated appendicitis or complications following surgery such as wound infection, wound dehiscence, continued ileus or postoperative bleeding to support the need for a continued inpatient stay.

As such, the requested inpatient hospital service was not medically necessary. The health plan acted reasonably with sound medical judgment and in the best interest of the patient.

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

Anemia 
Inpatient hospital stay

This is a case with patient with 2-year history of recurrent anemia, who has undergone a total of 9 transfusions with packed red blood cells, prior to this admission the patient presented to the emergency department with complaints of dizziness. Symptoms started 2 weeks prior to presentation, with dizziness gradually worsening, as well as associated shortness of breath, with exertion as well as palpitations. There was no orthopnea or paroxysmal nocturnal dyspnea. No fevers or chills or other respiratory symptoms. Home medications include oral iron supplementation. There was no known cause of the patient's anemia. Gastroenterology work-up or bone marrow studies have not been performed in the past. Uphold, in whole, the health plans determination of medical necessity. 
No, the inpatient hospital stay was not medically necessary This was a presentation of acute on chronic anemia, that typically gets resolved with blood transfusion, and can be managed under a lower level of care. This is the standard of care course, for many patients, who suffer from chronic anemia. The rest of the work-up for causes of anemia can be completed in the lower level setting. The patient did not demonstrate active gastrointestinal bleeding, which is life-threatening. The patient did not have hemodynamic instability. There is no evidence of hemolytic anemia, that is life-threatening. The patient is not hypoxemic or tachycardic. This patient's hemoglobin at baseline is quite low, reportedly 6 g/dL. The patient appears to have the ability to function fully, at a hemoglobin of 6 g/dL. The patient required further evaluation for the causes of anemia, but it did not require inpatient hospitalization.
The documentation lacked to provide evidence of hemodynamically unstable GI bleed, severe hemolysis, or sequestration of blood, that would warrant inpatient hospitalization. This is an acute exacerbation of a chronic problem, that is typically evaluated in the lower level setting. It was reasonable to admit the patient under a lower level status, to provide necessary blood transfusion, given the  homeless status, and inability to perform this through an infusion center.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertensive urgency
Treatment: Inpatient admission
The proposed treatment was not medically necessary.

This patient presented for evaluation of chest pain. The diagnosis of an acute myocardial infarct (MI) was ruled out by cardiac enzymes, which were negative, and the troponin from prior admission was possibly a lab error. There was no evidence of acute myocardial infarction, ACS, decompensated CHF, malignant arrhythmia or hemodynamic instability. Elevated BP was treated with oral medications. BP control, serial cardiac enzymes and non-invasive ischemic work-up, such as stress test or computed tomography (CT) angiogram could have been provided at an observational level of care. 

Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at an observational level of care.