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

Diagnosis: Macromastia with chronic back, neck and shoulder pain
Treatment: Surgical Services (bilateral reduction mammoplasty)

Summary: This patient had complaints of chronic back, neck and shoulder pain due to her large breasts. She had shoulder grooving and rashes in the folds under her breasts. Her surgeon performed a bilateral breast reduction in 2019 with the removal of 934 grams of tissue from the right breast and 772 grams of tissue from the left breast.

The insurer has denied coverage for bilateral reduction mammoplasty as not medically necessary. The denial was reversed. 

The bilateral reduction mammoplasty is considered medically necessary for this patient.  She had the classic symptoms for macromastia including back, neck and shoulder pain, shoulder grooving and rashes. Her surgeon performed a reduction of over 1700 grams of tissue total. Symptomatic macromastia is a mechanical problem and conservative treatments have been shown to be ineffective for this condition. Non-operative treatments are unlikely to improve her pain, and surgery provides the only real chance for symptomatic relief.  Breast reduction is the only treatment that is proven in the medical literature to be curative for symptomatic macromastia, and hundreds of peer-reviewed studies confirm the benefit of breast reduction surgery for women with upper torso pain due to breast hypertrophy. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

The patient with opiate use disorder and cannabis use disorder, no psychiatric history, previous treatment for substance use disorder, pending drug-related legal charges with current mandate for treatment was admitted for inpatient detoxification. The health plan's determination is upheld.

The substance use disorder inpatient detoxification is not medically necessary.

The patient does not have any substance use diagnoses that are associated with possible life-threatening withdrawal (i.e. does not use alcohol, benzodiazepines, or barbiturates). There are no chronic physical health conditions that could be significantly destabilized by opiate withdrawal. Patient has no history of psychiatric disorder or any reported history of unsafe behaviors or psychiatric symptoms in context of previous substance abuse treatments. Patient denied any gang involvement and denied any history of domestic violence or safety concerns at home. There is no mention of any substance use disorder history in  family. The admission LOCADTR completed by the facility included that the patient did not have a home environment that was conducive to early recovery. However, the information on the home environment is incongruent with this statement. The submitted documentation does not support that the home environment was not supportive. The initial COWS was 13 which is the lowest number in the moderate range on COWS scoring.

Given the lack of psychiatric and medical comorbidity, the fact that the patient does not use substances associated with direct life-threatening withdrawal risk, and was not demonstrating severe withdrawal, the assertion of the program that the patient did not have a supportive home environment is most likely what led to the recommendation on the admission LOCADTR for inpatient detoxification. However, as stated above, this assertion is not supported with the charting, including the multiple notes from a certified substance abuse counselor. This reviewer completed the admission LOCADTR with the information available/supported in the medical records and the results were outpatient level of care with medication assisted treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma following accident on bicycle
Treatment: Inpatient Hospital Services

Summary: This patient presented to the emergency department (ED) with the history of headache and neck pain after being hit by a high speed car while on his bicycle. He was thrown off his bike and hit his head on another car and had +/- loss of consciousness. He complained of neck pain and headache. He had no visual disturbance, weakness, numbness, tingling, nausea or vomiting. Exam revealed vital signs stable with strength 5/5 in all extremities and no sensory deficits, normal gait and coordination. He had a left cheek abrasion. The plan included trauma labs, computed tomography (CT) of the head, maxillary/face, spine, pelvic x-ray and chest x-ray. The patient was admitted for further management. Labs revealed elevated white blood count and hematocrit of 38.9. Chest x-ray and x-ray of the pelvis were unremarkable. CT angiogram of the head with contrast did not show any lesions from the trauma. He did have an arteriovenous malformation (unrelated to the trauma). X-ray of the knee was normal. CT scan of the sinus and maxilla facial bones was without fracture. CT of the cervical spine and thoracic spine did not show a fracture. The patient was seen the day after admission with stable vital signs as he did well overnight and the plan was for discharge today with referral to neurology.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.
 
Based upon the records provided, this reviewer agrees that the inpatient admission was not justified at the acute level of care as the patient presented with non-penetrating trauma to the head and neck following being hit by a fast moving motor vehicle. The work up was negative including all x-rays and CT scans. Serial exams were unremarkable and the patient was discharged. As noted in the admission, the patient was admitted to be observed with serial exams. Therefore, all the patient needed was admission for a 23 hour observation without an acute admission. According to Milliman Care Guidelines General Recovery care 23rd Edition multiple trauma hospital admission is indicated when patients with significant multiple trauma requires inpatient care for 1 or more of the following: Major surgical and post procedural care; Non operative care of significant injury, such as observation.  This patient did not have any of the above indications that would have required inpatient admission rather than just observation. He sustained non-penetrating trauma with work-up being negative. All that was required was a 23 hour observation and not an acute inpatient hospital stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain 
Treatment: Inpatient Hospital

Summary: This patient has a history of diabetes mellitus, hypertension, thyroidectomy and coronary artery disease with percutaneous intervention and stents in the left circumflex and right coronary artery six years earlier. A coronary angiography 11 months prior to presentation revealed patent stents and mild luminal irregularities in the mid, and non-obstructive disease in the distal left anterior coronary artery, with left ventricular systolic function 60%. In 2018 she noted left sided chest pain radiating to her back, with epigastric discomfort and mild nausea for which she used sublingual nitroglycerine without relief. She also had left upper extremity discomfort, worse with pushing, for three days. Emergency Medical Services were called with initial vital signs at 22:32 showing blood pressure 154/84, heart rate 96, and oxygen saturation on room air 98%. She was treated with aspirin 162 mg with improvement in pain level. Initial vital signs in the Emergency Department (ED) at 23:20 included blood pressure 148/84, heart rate 96, respiratory rate 17, and oxygen saturation on room air 98%.  Electrocardiogram (EKG) at 23:18 and 23:25 were normal, as was her chest x-ray. Laboratory test results from 00:11 included white blood count (WBC) 7.7, hemoglobin 12.7, creatinine 0.71, brain natriuretic peptide (BNP) 12, and troponin <0.03 with subsequent troponin levels <0.03 at 03:14 and 0.03 at 07:11. Left upper extremity venous ultrasound was normal. Echocardiography revealed left ventricular hypertrophy, severely hypokinetic anterior and anteroseptal wall motion, all other segments mildly hypokinetic, and left ventricular ejection fraction 41%. She was treated with Maalox and proton pump inhibitors and discharged.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

There is no evidence that this patient required an acute inpatient level of care to determine that her chest discomfort was not related to acute coronary syndrome. The inpatient hospital stay was not medically necessary for this patient because evaluation testing and monitoring could have been completed in the ED or at an observation level of care. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gangrene and osteomyelitis
 
Treatment: Skilled Nursing Facility Stay

The insurer denied the Skilled Nursing Facility Stay. The denial was upheld. 

This is a male patient with a history of traumatic brain injury (TBI), alcohol dependence and seizures. He presented to the hospital for surgical amputation of his right digits 1-3 and left foot digit 1 due to gangrene and osteomyelitis. He was admitted to a skilled nursing facility for post- operative wound care and rehabilitation. 

Continued skilled nursing facility (SNF) level of care after several weeks was no longer medically necessary due to the patient's improved functional ability.  He also did not require complex wound care.  According to a nursing note dated at that time, the patient was independently ambulating without the use of a device.  Wound care was routine and on several occasions, the patient actually refused treatment.  There are no specific complex nursing needs or acute medical issues that required ongoing inpatient skilled nursing or medical services.   The patient could have been safely transferred to a lower level of care.  From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the continued SNF stay was no longer medically necessary.  The insurer acted reasonably, with sound medical judgment, and in the best interest of the patient.

The insurer acted reasonably, with sound medical judgment, and in the best interest of the patient.

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

Diagnosis: Acute Anemia
Treatment: Inpatient Hospital 

Summary: This patient with a history of menorrhagia was referred the Emergency Department (ED) by her private physician because of abnormal complete blood count (CBC). The patient also reported shortness of breath and lightheadedness. Her hemoglobin/hematocrit was 6/21.9. The patient was admitted to telemetry with the diagnosis of acute anemia and was transfused with 2 units of blood. Her symptoms improved and she was discharged home to follow-up with her gynecologist as an outpatient.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

This patient was not actively bleeding but she was anemic and symptomatic for anemia. This patient also fulfills the transfusion guidelines for use of blood components: her hemoglobin was less than 8g/dl and she was symptomatic, so transfusion was necessary. Could transfusion be done as an outpatient? It is obvious that in this day and age, transfusions are done routinely in outpatient settings (oncology clinics, infusion centers even at home). So the need for transfusion is not a reason for admission. This patient's transfusion was started in the ED. She could have been monitored for a few hours in the ED, her CBC repeated and then sent home to follow-up with her primary physician or gynecologist for management of her history of vaginal bleeding. Nothing was done in the hospital that could not be done as an outpatient. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Bronchiectasis, Pneumonia
Treatment: Inpatient Hospital Admission

Summary: This patient with a history of tuberculosis (treated 10 years ago) presented to the Emergency Department (ED) with complaints of cough productive of whitish sputum for one week and one episode of vomiting on the day of presentation. The patient also complained of some shortness of breath and a choking sensation. Lung examination revealed a left lung with diffuse crackles. The patient received nebulizers in the ED after which she improved. A chest x-ray showed emphysematous lungs. There were findings of old tuberculosis in the biapical regions. There were significant cystic bronchiectatic changes noted in the left lung. A CT of the chest revealed severe bronchiectasis with mild pneumonia. The patient was initially treated with Ceftriaxone and Azithromycin for possible community acquired pneumonia.

The insurer denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

Based on presentation, the patient did not need acute hospitalization. She was afebrile and hemodynamically stable. The patient only had mild leukocytosis. The lactate level was mildly elevated, but the patient had no anion gap or metabolic acidosis. It may have been from her Albuterol nebulizers. The patient was not in any acute distress. She was not hypoxic. Her pneumonia was mild with a CURB 65 (Pneumonia Severity Score) of 0. The patient felt better after treatment in the ED. She could have been placed in Observation while diagnostic testing and treatment was initiated. The patient remained afebrile and hemodynamically stable overnight. She was able to tolerate oral intake.  The patient could have been discharged home on oral antibiotics after a period of observation with close follow-up in an outpatient setting.
Appeal type: Medical necessity
Decision: Upheld

This is a case about a male with a history of multiple sclerosis (MS) who is admitted to the hospital for acute influenza A infection. 

The inpatient hospital admission is not medically necessary. It is noted that he had normal vital signs immediately upon arrival and this remained true throughout the admission. Based on the available documentation, the patient did not require an inpatient level of care. He could have been cared for at a lower level. The health plan's determination is upheld.
Appeal type: Medical necessity
Decision: Upheld

Chest pain
Inpatient hospital

The patient is a female with known systolic heart failure with reduced ejection fraction (25%)- non ischemic, pacemaker/ automatic implantable cardioverter defibrillator (AICD); atrial fibrillation on anticoagulation, and diabetes requiring insulin. She presented to the emergency department (ED) with chest pain of pleuritic nature. Her vital signs were normal. Exam showed normal cardiac exam with evidence of bibasilar rales on lung exam and 1+ lower extremity edema. Her electrocardiogram (EKG) was unremarkable and she had a normal troponin. Brain (or B-type) natriuretic peptide (BNP) was > (greater than) 500. A chest x-ray (CXR) showed changes of pulmonary edema with small bilateral effusions.
She was admitted to an inpatient telemetry bed with diagnosis of acute on chronic congestive heart failure (CHF) exacerbation. 

The health plan's determination is upheld. Based on the available clinical records, the inpatient hospital admission is not necessary. The patient's chest pain was deemed related to a CHF exacerbation (acute on chronic) for which she has had recent similar episodes and also had prior negative angiograms in the recent past as documented. Although the patient has a low ejection fraction (EF), the treatment of CHF with no hemodynamic compromise could have been started at a lower level of care as she was hemodynamically stable. In the process, acute coronary syndrome could also have been ruled out. Despite her low EF, the patient is deemed low risk for serious adverse event based on Ottawa heart failure risk stratification. She did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Febrile seizure
Treatment: Inpatient Hospital Admission

Summary: This patient presented to the Emergency Department (ED) with fever and seizure. The reported fever at home was of 101 Fahrenheit and he was noted to be rolling his eye balls which lasted for 2 minutes. Highest fever in the ED was 102.5F. He had a past history of febrile seizure. The diagnosis was simple febrile seizure, because the duration of seizure was less than 2 minutes and there was no prolonged post-ictal phase. The patient was admitted for further management. He was treated with intravenous (IV) fluids, Motrin, Tylenol, and Ceftriaxone.

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

There was no evidence of sepsis and although he continued to have low-to moderate grade fever during his time in the ED, this has no bearing on the incidence of recurrence of a febrile seizure. The blood workup was benign, including complete blood count and urinalysis, and there was no indication for administering IV antibiotics, as there was no evidence of a bacterial infection. The reason for admission is simply stated as "for observation", and no other medical decision making is documented. This reviewer agrees with the insurer that because the vital signs were stable and there was no clinical or laboratory indication for admission, the patient could have been treated in the ED and then followed as an outpatient.
Appeal type: Medical necessity
Decision: Upheld

This patient has a history of anemia and uterine cancer with surgery and radiation. The patient  presented to the emergency department with one episode of dark red blood per rectum and was admitted to the hospital.  The health plan's determination of medical necessity is upheld in whole.  A lower level of care would be appropriate.  Therefore the  inpatient hospital admission is not medically necessary.
This patient presented to the hospital with one episode of hematochezia, with stable vital signs. The suspicion was for an upper GI bleed. The patient was appropriately admitted to the hospital, though a lower level of care is more appropriate for this type of presentation. A typical severe GI bleed, would produce tachycardia, hypotension, hematemesis, or recurrent melena. The patient did not have lacks any of these high risk indicators.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Schizoaffective Disorder, psychotic symptoms, depressive symptoms, suicidal ideation with a plan
Treatment: Inpatient admission, medication management

The insurer denied the continued inpatient mental health services. The denial was modified (partially approved - one of 5 days was allowed)

This patient was brought in by ambulance to the Emergency Room (ER) for an emergency psychiatric evaluation. He reportedly had command auditory hallucinations telling him to hurt himself, had depressed mood, feelings of hopelessness, helplessness, and worthlessness, and had self-injurious behavior by cutting himself with a razor.  He was non-compliant with medications.  He was using crack/cocaine.  He had past suicide attempts and multiple past psychiatric hospitalizations.  He had a reported diagnosis of Schizoaffective Disorder.  He was unemployed and had limited education.  He reportedly had Abilify Maintena IM, started Clozapine and it was increased.  He was discharged.

The insurer denied stated that his mood was stable, he denied thoughts of self-harm or hallucinations, and had no acute symptoms requiring continued hospital treatment.  

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia report 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.  

In this case this patient still had psychotic symptoms including internal preoccupation, and the notes also reported that he was ambivalent in suicidality, was isolative, not interactive, and was smiling inappropriately.  He had reports of command auditory hallucinations on admission with self-injurious behavior, depressed mood, feelings of hopelessness, helplessness, and worthlessness on admission with crack/cocaine use so he was considered at risk if still experiencing psychotic symptoms and not ready for discharge yet.  That was the case on first day denied as he still had psychotic symptoms of responding to internal preoccupation.  He had a reported history of multiple past psychiatric hospitalizations and had medication changes including adding and increasing Clozapine and also took Abilify Maintena IM also so he had an active psychiatric treatment plan.  However, as of second day of the denial period there were no further reports of psychotic symptoms, severe depressive symptoms, or suicidal ideation, plan or intent.  There were no reports of specific identifiable or quantifiable treatment goals or objectives that could only have been achieved in a 24 hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting at that time.