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

Diagnosis: Hypertensive Urgency
 
Treatment: Inpatient Admission

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

This case involves a male patient with a history of hypertension, obesity and tobacco abuse who presented to the Emergency Room in mid-2019 with high blood pressure.  The patient reported being started on 25 mg of metoprolol for high blood pressure the month before this admission.  The blood pressure on initial assessment was 213/132 and the patient had a body mass index of 36.8.  A chest x-ray was done and did not reveal any pulmonary disease.  An electrocardiagram revealed sinus rhythm with premature ventricular complexes and left ventricular hypertrophy with repolarization abnormality.  There was a carbon dioxide (CO2) level of 33 and a glomerular filtration rate of 82.77.  The urinalysis revealed trace glucose, trace ketones and trace protein.  During the patient's emergency room stay, the nurse documented that the patient's blood pressure was improving with a reading of 173/91 and that the patient denied chest pain, shortness of breath, headache, or dizziness.  The patient was admitted to the telemetry unit with a diagnosis of hypertensive urgency.  The patient's vital signs were closely observed and the patient most likely had a diagnosis of hypertensive cardiomyopathy, per physician report.  His medications were evaluated and changed as needed; he was placed on a low-sodium and cardiac diet. There was no documentation of hemodynamic instability, acute cardiac or peripheral ischemia, cardiac arrhythmias of immediate concern, severe heart failure, respiratory, neurologic, or abdominal abnormalities, or severe electrolyte abnormalities.  The patient's blood pressure was 160/80 at the time of discharge
 

MCG for Hypertension admission for inpatient care consists of criteria including hypertensive emergency indicated by systolic blood pressure (SBP) > 180mm Hg or diastolic blood pressure (DBP) > 120 mm HG with evidence of acute or worsening target organ damage.  Target organ damage is indicated by altered mental status, cerebral infarction, myocardial ischemia, heart failure, aortic dissection, seizure, and other acute or worsening end organ damage due to severe hypertension or oral antihypertensive treatment not feasible due to uncooperative patient.  Alternatives to inpatient care include care in the emergency department, rapid treatment site, urgent care center or medical office for a patient without progressing target organ damage to assess for gradual lowering of the blood pressure and observation, as well as close outpatient follow-up with continuing gradual lowering of blood pressure over the ensuing 24 to 48 hours.  

Based on the above, the medical necessity for the inpatient hospital services at the acute level is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cellulitis of right upper extremity
 
Treatment:   Inpatient admission, medication, monitoring

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

This patient had a past medical history significant for breast cancer, status post mastectomy, lymphedema and depression. She presented to the Emergency Department with complaints of right arm erythema, swelling and pain.  Vitals on presentation included: a temperature of 99.4F, a blood pressure of 119/64, a pulse of 74, a respiratory rate of 22, and an oxygen saturation of 98% on room air.  Laboratory results included the following: a white blood cell (WBC) count of 6.43, a hemoglobin of 12.8, a hematocrit of 40.1, a creatinine of 0.8, and a glucose of 84.

The patient was started empirically on intravenous antibiotics (ceftriaxone) for a right upper extremity cellulitis.  Infectious Diseases consulted and recommended switching antibiotics to Cefazolin.  All cultures remained negative.  Doppler of the arm was negative for a deep vein thrombosis (DVT).  The patient remained afebrile and hemodynamically stable and was discharged to continue outpatient management and oral antibiotics.

According to documentation, patient presented with right arm cellulitis associated with chronic lymphedema of the affected limb. There was no evidence for a systemic infection and no surgical intervention was deemed necessary. 

Based on above findings, criteria were not met for acute inpatient hospitalization. The carrier's denial of coverage for the inpatient hospital services is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

The patient has with metastatic pancreatic cancer and a new intraparencyhmal hemorrhage. The patient was transferred from Mount Sinai Hospital to Calvary Hospital for end of life care. 

The health plan's determination is upheld. The Hospital Transfer for End of Life Care is not medically necessary for this patient. There is a paucity of clinical information provided indicating that this care cannot be adequately provided at Mount Sinai, which lists 62 physicians on its staff that are part of their palliative care program.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Issue under review: Continued inpatient admission

Determination:
The Continued inpatient admission was not medically necessary.

The continued inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The inpatient treatment of this patient's substance use disorder did not require the continued structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of schizoaffective disorder, depressed type and ongoing substance use disorder with alcohol and use of crack cocaine and cannabis. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted continued inpatient level treatment. There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatment recently, as noted in the clinical summary. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder mental health treatment with a past history of recent treatment episodes for the co-occurring disorders. Thus, continued inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.

This answer is consistent with New York State LOCADTR 3.0 Criteria and with established practice guidelines, the scientific literature, and ASAM Criteria, as referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Paranoid Delusions and Worsening Mania
 
Treatment: Inpatient Hospitalization

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

This a female patient admitted to this inpatient mental health treatment in this hospital on in early 2019 due to psychotic and manic symptoms, including paranoid and grandiose delusional thinking, disorganized thinking, racing thoughts, flight of ideas, poor reality testing, agitation, and feelings of hopelessness and helplessness. It was reported that she took Zyprexa and Klonopin. Health care provider stated that she was free of suicidal ideation or psychosis and was able to care for self. They stated that she no longer required 24-hour hospital treatment then, and they recommended a less restrictive level of care. She improved and was discharged.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate. They also report that patients with aggression, homicidal or suicidal intent, plan, or behavior, manic episodes, psychotic symptoms, or severe agitation are candidates for inpatient hospitalization. In this case, this patient had initially presented with manic and psychotic symptoms, but during hospitalization there were no further reports of manic episodes or psychotic symptoms. Further documentation reports that the patient was stable over the past week, and she did not have a labile mood, aggression, suicidal or homicidal ideation, or hallucinations. It was noted that her speech was linear and not pressured. There were no reports of manic episodes, aggression, disruptive behavior, paranoid delusions, hallucinations, disorganized speech or thought process, homicidal ideation, plan, or intent, or severe agitation, acute medical instability or severe withdrawal requiring hospital treatment. The patient had no further severe psychiatric symptoms reported. Additionally, there were no reports of specific identifiable or quantifiable treatment objectives that could only be achieved in a 24-hour acute inpatient hospital setting or achieved in a less restrictive level of care. 

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

The patient is a male who had some gastrointestinal (GI) discomfort which he attempted to manage by drinking more beer. 4 days later he had some persistent coughing and pink frothy sputum and went to the emergency room. Other than the cough and the sputum he reported feeling well. Workup for pulmonary embolism and acute coronary syndrome were negative. CT showed some minor infiltrates. He had borderline hypoxemia in the ED with a room air sat 89 percent. He was kept overnight and was not hypoxic after that. He was discharged the next day. The subject under review is the medical necessity of the inpatient stay. The health plan's determination of medical necessity is upheld, in whole. The inpatient stay was not medically necessary for this patient. The patient presented with coughing, and a workup was done for pulmonary embolism and acute coronary syndrome, both of which were negative. He was monitored overnight for hypoxia and had no further episodes overnight. There was no evidence of any acute medical problem that required prolonged monitoring, suggested instability or required complex inpatient therapy. The patient's care could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance/Alcohol Abuse
 
Treatment: Inpatient substance detoxification

The insurer denied inpatient substance detoxification. The denial was reversed.

This patient is a male who was admitted to inpatient substance detoxification treatment for detoxification from alcohol and substances. He reportedly had withdrawal symptoms including tremors, diarrhea, yawning, sleeping problems, irritable and anxious mood, chills, headache, and sneezing. He reportedly was drinking 3 pints per day, using $100-$500 per day of crack/cocaine, 2-3 grams of heroin, and smoking up to 6 blunts per day of cannabis. He reportedly had a positive toxicology for opiates, cocaine, and THC.
He had a history of depression and was homeless for 6 months. His longest reported abstinence was when in prison.

This reviewer disagrees with the decision to deny coverage for inpatient substance detoxification treatment. 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. In this case this patient had been using multiple serious substance and drinking large amounts of alcohol and was at high risk for severe, complicated, and life threatening withdrawal and also overdose. 

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

Diagnosis: Right renal colic
Treatment: Inpatient admission 

Summary:

The patient is a male. He was admitted with right renal colic.  A ureteral stent was placed in the OR.

An acute inpatient level of care was not medically necessary.  Care could have been provided at a lower level of care.  He was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis.  Following admission, there were no unstable vital signs reported.  He did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, severe vomiting.  Pain control, IV antibiotics and IVF followed by stent placement in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient was seen in his Cardiologist's office with exertional chest pain for one week. The pain was relieved at rest. The pain was also associated with dyspnea and fatigue. The patient also was complaining of 4 pillows orthopnea. The patient had a past medical history of coronary artery disease with previously placed coronary stents. He also had history of hyperlipidemia, diabetes mellitus (DM), asthma and gastritis. In the office his vitals were stable. His physical examination was unremarkable. The patient's electrocardiogram (ECG) did not reveal any ischemic changes. The Cardiologist felt that the patient had unstable angina. The Cardiologist recommended to proceed with coronary angiography. The patient was admitted to the hospital for the procedure and discharged the following day. The health plan denied the admission as not medically necessary. The health plan's determination is upheld.
The patient's Cardiologist scheduled him for coronary angiography. However, the patient came for the procedure from home; he was not referred for hospital admission from the office. The procedure, including coronary intervention, was done electively. The procedure did not have any complications and the post-procedural course was also uneventful. The patient had severe coronary artery disease, but there was no acute occlusion of the coronary artery, which would justify inpatient admission.
IV hydration and electrolyte replacement would not be sufficient to meet inpatient admission criteria. The patient could have received treatment at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diagnostic Catheterization  
 
Treatment: Inpatient Admission


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

The patient is a male with a past medical history notable for diabetes mellitus, systolic heart failure, coronary artery disease, chronic kidney disease, non ST elevation myocardial infarction (NSTEMI), and constipation.  This patient presented in early 2019 for an elective, outpatient cardiac catheterization with possible coronary angioplasty.  He underwent placement of a drug-eluting stent to the right coronary artery for an 80% stenosis discovered at the time of diagnostic catheterization.  There were no procedural complications, and the patient was then admitted for further monitoring.  The patient remained hemodynamically stable, was ambulatory, and was tolerating oral intake.  There were no vascular access complications.  

Inpatient admission status was not medically necessary for this patient.  Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this is an elective outpatient procedure which allows for up to 23 hours of observational level monitoring in the hospital.  The clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate.  There were no extenuating clinical circumstances in this case which warranted inpatient admission status following elective cardiac catheterization and stenting.  


The carrier's denial of coverage for the inpatient hospital services was upheld.  The medical necessity is not substantiated
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cannabis use disorder
Treatment:  Inpatient stay

The proposed treatment, Inpatient rehabilitation is not "medically necessary"

The patient is an adult male who was admitted to inpatient level services for treatment of cannabis use disorder; the patient had been using cannabis (marijuana/hashish) with up to two blunts daily over a 23 year time frame.  His self-referral was prompted by family stress and the desire to stop his use.  He had no past history of formal substance use disorder treatment. 

The inpatient substance abuse rehabilitation treatment, in this case scenario, was amenable to treatment at a lower level of care.  The patient was 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 family support/pressure for the substance use disorder treatment with fair insight, as noted in the clinical summary.  Thus, the requested benefit of Inpatient rehabilitation was not medically necessary for this patient.  This answer is consistent with prevailing standards of professional practice, ASAM Criteria, and the scientific literature, referenced below, as well as New York State instruction for medical necessity reviews together with the application of NY State OASAS LOCADTR 3.0 Criteria applicable in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient is a young male child with medical history significant for late preterm birth at 36 weeks' gestation and small for gestational age with birth weight of three pounds. He presented to the ED with several days of fever to 104, cough, and decreased intake. The family had recently returned from a trip to Bangladesh, and the child began to feel feverish on the plane home. He was seen in a clinic for fever and cough, with recommendations to continue Tylenol and Motrin. He had some post-tussive emesis as well as a couple episodes of diarrhea. 

The patient's vital signs in the ED included temperature 98.0, heart rate 129, respiratory rate 28, and 99% saturation in room air. Examination was significant for no distress, well-hydrated appearance, moist oral mucosa, coarse breath sounds bilaterally with fair air entry, no retractions, good perfusion, and non-vocal neurologic exam. Laboratory evaluation revealed WBC (white blood cell) count 28.5K with 76.5% neutrophils, mild hyponatremia with sodium 134, elevated CRP (C-reactive protein) 25.05, and negative influenza/RSV (respiratory syncytial virus). Chest x-ray revealed right upper lobe infiltrate with small right pleural effusion. Blood cultures were obtained that were ultimately negative. There was concern for Salmonella enteritis because of the recent travel and occasional diarrhea. 

The patient was given a dose of ceftriaxone as well as IV fluids and admitted for management of pneumonia. Admission orders included thoracic ultrasound for pleural effusion, treatment with ampicillin, stool cultures, and regular diet. He was afebrile overnight, with some improvement in cough but still poor appetite. He had no respiratory distress or oxygen requirement. Ultrasound failed to show evidence of pleural effusion. 

Two days after presentation, the patient's appetite was much improved, he remained afebrile and stable in room air, and was deemed appropriate for discharge home. 

This patient presented to the ED with fevers, cough, and poor appetite. He had not been treated in the outpatient setting except with antipyretics. Chest x-ray revealed an upper lobe pneumonia with suspected effusion, and laboratory evaluation revealed elevated inflammatory markers and WBC count. While it was not unreasonable to monitor him for adequate oral intake, he was overall hemodynamically stable with no oxygen requirement, no respiratory distress, and no signs or symptoms of sepsis. He did not require acute inpatient admission, and he could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient has a past medical history of LVAD (left ventricular assist device) due to cardiac failure, coronary artery disease (CAD), hypertension (HTN), atrial fibrillation, aortic regurgitation, diabetes mellitus (DM), gastroesophageal reflux disease (GERD), left breast cancer s/p mastectomy in 2001 and right breast cancer s/p mastectomy in 2014, reconstructed with silicone breast implants, and wide local excision, capsulectomy, and removal of implant secondary to recurrent breast cancer invading the capsule of her implant (1 1/28/18). The patient presented for removal of left breast implant material, capsulectomy, and irrigation. The patient underwent the procedure and tolerated it well.

The health plan's determination is overturned. The inpatient stay is medically necessary. This patient has multiple medical problems including a history of cardiac failure with LVAD placement. The patient has minimal cardiac reserve and could not have survived a postoperative bleeding episode. Capsulectomy has a reasonable high risk of postoperative hematoma. Most patients have the physiologic reserve to tolerate even significant bleeding following breast surgery, but such a complication likely would have been fatal in this patient. Bleeding, a known complication of capsulectomy, would have been fatal in this female with an ASA class 4 rating unless treated emergently. Admission for monitoring was required. For her special circumstance, admission for what is generally an outpatient procedure was appropriate.
Appeal type: Medical necessity
Decision: Overturned

The patient has Duchenne muscular dystrophy. The patient was born vaginally at term following a normal pregnancy. There were no neonatal problems. The patient crawled at 9-10 months, walked at 16 months and talked at 13 months. The patient's mother became concerned regarding the patient at the age of 4 years, when she noted on a family ski trip that the patient was unable to walk when wearing ski boots. The patient was diagnosed with Duchenne muscular dystrophy, having a deletion in exon 52. The use of Exondys 51 is under review. 

The health plan's determination is overturned. The Exondys 51 is medically necessary for this patient. The patient has Duchenne muscular dystrophy, a progressive and ultimately fatal genetic neuromuscular disease. The patient has a deletion in exon 52. The patient is a suitable candidate for Exondys 51. In its approval letter for the drug issued on 9/16/2019, the Food and Drug Administration (FDA) stated: "This new drug application provides for the use of Exondys 51 (eteplirsen) Injection, 50 mg per mL, for the treatment of Duchenne muscular dystrophy (DMD) in patients who have a confirmed mutation of the Duchenne muscular dystrophy (DMD) gene that is amenable to exon 51 skipping."