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

Diagnosis: Sepsis due to influenza, acute bronchiolitis, acute respiratory infection
Treatment: Inpatient Hospital Admission

Summary: This patient presented to the Emergency Department (ED) with persistence of fever, cough, congestion, and runny nose after being seen four days prior and diagnosed with influenza and sent home on oseltamivir. He was seen by the ED medical doctor (MD) at 18:30 and decision to admit around 01:30 because he was described as still looking sick despite administration of fluids. Work-up included abnormal findings of leucopenia 3.2 with 32% neutrophils (this is consistent with influenza) a normal blood urea nitrogen and creatinine, flu A antigen positive, and on chest X-ray "peripheral peribronchial thickening" with no focal pneumonia.
  
The insurer denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld. 

This reviewer sees no mention of hyperinflated lungs that would be consistent with bronchiolitis. He was described at various points in the ED as "fussy but consolable," "glassy look," "febrile despite Tylenol", "croup-like coughing" and admitted "for observation.".  However, there is no evidence in the record that there was a toxic-appearance. He was treated with intravenous fluids, and Tamiflu was continued. He was also treated with, azithromycin, albuterol, Tylenol, and Motrin as needed.  He did not have pneumonia.  Also, there is no evidence in the record that there was persistent wheezing; wheezes were only noted on the pediatrics physical exam, so he probably did not need treatment with nebulized bronchodilator therapy.  All his observation, follow-up and treatment could have been accomplished at an alternate level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure disorder, past medical history of uterine fibroids
 
Treatment: Inpatient admission, diagnostic testing and medication management.

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

This patient was found lying on the floor.  Per her son, he witnessed the patient having two seizures, and she remained unconscious.  As per the Emergency Medical Services (EMS) staff, the patient kept removing the non-rebreather mask from her face.  The patient was snoring on the floor, she woke up for EMS but was in a post-ictal state.  In the emergency room, the patient was alert and oriented x3, calm, breathing room air in no apparent distress.  The patient reported that her first seizure was six months prior, and this was the second time she had a seizure episode, and she was not taking any seizure medications.  There was documentation of hemoglobin and hematocrit (H&H) of 6.5/20.8 and the patient received 1 unit of packed red blood cells.  The patient was admitted to the hospital for continued care for seizure activity, of which none were  noted or reported by the patient since she was seen in the Emergency Room.  The patient ambulated with a steady gait, denied any pain or discomfort.  The patient had a chest x-ray x2 views with an impression of peri-bronchial thickening likely infectious or inflammatory.  The patient had an MRI of the brain with an impression of unremarkable MRI of the brain.  Post transfusion of 1 unit of blood, the H&H was documented as 8.4/27.6.  The patient was discharged from the hospital with discharge diagnoses of seizure, resolved, chronic anemia, and essential hypertension.  The patient was discharged home unaccompanied; no distress was noted upon discharge.

MCG lists the clinical indications for admission to inpatient care for seizure as, hemodynamic instability, repetitive seizures not controlled with emergent treatment, brain disorder, cardiac arrhythmias of immediate concern, metabolic disorder, recurrent seizure, outpatient anti-seizure regimen cannot be established, cerebral bleeding, hydrocephalus or vasospasm monitoring, increased intracranial pressure or cerebral edema monitoring, other condition, treatment or monitoring requiring inpatient admission.  

MCG lists the indications for observation care admission criteria for seizure as, vital sign abnormality, first seizure, specific etiology that requires short-term, less than 24 hours observation, treatment or correction, adjustment that requires observation for 24 hours or less, altered mental status upon post-ictal presentation to the hospital.  

Inpatient criteria were not met.
Appeal type: Medical necessity
Decision: Upheld

The patient is a  man with previously diagnosed substance use disorders and depression who was admitted to an acute psychiatric unit for treatment of depression, suicidal thoughts, and auditory hallucinations. 

The patient initially presented to the psychiatric emergency room. In notes he was described as disheveled and disorganized and depressed appearing. He had recently become street homeless after being kicked out by his girlfriend. He endorsed symptoms consistent with depression. He endorsed suicidal ideation without a specific plan or intent. He endorsed two weeks of command auditory hallucinations to kill himself and hurt others. He had last used cocaine and heroin on the day prior to presentation intravenously. He tested positive for both cocaine and opiates. He endorsed some common symptoms of opiate withdrawal. He was diagnosed with major depression. He was assessed a risk to himself and noted to be hopeless and feeling worthless.

The health plan denied payment for part of this stay after finding that it was medically unnecessary. The health plan's determination is upheld. The latter part of the stay was not medically necessary. During the denied dates, the patient consistently denied suicidal thoughts, homicidal thoughts, or psychotic symptoms. He was future-oriented as evidenced by his multiple recorded statements that he was looking forward to discharge, inquiring about discharge, making discharge plan preferences known, and making statements about his plans for living and employment after discharge. The notes from multiple disciplines are consistent in documenting that he did not have behavioral issues and was visible, social and engaged with group therapies and in the milieu. No standing medications were changed. The submitted documentation does not support that this level of care was clinically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of alcohol use disorder who was admitted for detoxification from alcohol on 11/26/18, reportedly just one day after completing detoxification at another facility.  Psychiatric evaluation on 11/26/18 indicated that the patient had no "direct psychiatric complaints" at the time of admission.  Dates of service in question are 11/26/18 through 12/01/18 at the inpatient substance abuse level of care.

The health plan's determination is upheld.  The patient did not require immediate hospitalization for life-threatening medical conditions or a severe psychiatric crisis.  Alcohol was the substance with the greatest potential to cause harm to self or others.  The patient clearly had a diagnosis of and alcohol use disorder.  The patient did not have a substance use disorder in full remission.  The patient did not have serious medical symptoms that needed to be managed in an inpatient rehabilitation setting to be effective.  The patient did not have serious psychiatric symptoms that required inpatient rehabilitation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Recurrent Gallbladder Cancer
Treatment:  Transfer to Hospital for End of Life care
The Transfer to Hospital for End of Life care is not medically necessary.

The patient in this case is a woman with recurrent gallbladder adenocarcinoma.  She was treated previously with surgery and chemotherapy.  She presented to the hospital with a one day history of abdominal pain.  She has a prior history of gastric outlet obstruction treated with gastrojejunostomy.  She had abdominal pain, nausea and vomiting before presenting to the emergency department.  Her pain did not respond to oral Dilaudid. 

The patient was admitted and treated for pain.  Celiac plexus nerve block was recommended, but she deferred.  Palliative care was consulted.  It was decided to transfer to Hospital for end of life care.

Records indicate that this patient had pain at her PTC tube site, which was the reason for admission.  She had met with palliative care, and nerve block was recommended.  Progress notes indicate that the plan was for the nerve block followed by discharge.  It was noted that she wanted to wait three weeks to have the nerve block performed.  There is no documentation indicating that she had pain or any other symptom that was sufficiently difficult to control such that she would require continued acute care inpatient admission, especially when the plan had been discharge, and there was no indication that her pain significantly intensified.  There is also no documentation that she had any other symptom or acute medical condition that would have required continued acute care hospitalization.  Finally, records also do not support the need for inpatient hospice based on either uncontrollable symptoms or rapid progression of her disease process with expected imminent death.  Therefore, based on provided records there is no support for the medical necessity of transfer to Hospital.
Appeal type: Medical necessity
Decision: Upheld

The patient has hypertension (HTN), chronic kidney disease (CKD), type 2 diabetes mellitus (DM), and rectal cancer status/post (s/p) resection with colostomy. The patient was sent to the emergency department (ED) on 11/30 18 after labs revealed potassium of 7.7 and Hgb (hemoglobin) < (less than) 6.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The record shows the patient had hyperkalemia, chronic kidney failure, and anemia. The patient did not have severe ECG changes with the hyperkalemia as his PR interval and QRS interval were normal. The hyperkalemia responded to treatment and could have been safely treated at the observation level of care. The anemia was due to chronic illness and he was not actively bleeding. He had no hemodynamic instability. The patient responded to the blood transfusion and Hgb was stable thereafter. This could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Issur under review: Stelara

Determination:
Stelara is medically necessary.

The current treatment guidelines, which are in accordance with nationally accepted standards of medical practice for moderate to severe plaque psoriasis, recommend typical first line treatments such as topical corticosteroids and calcipotriene, followed by typical second line treatments, such as ultraviolet phototherapy, oral systemic treatments (methotrexate, cyclosporine) and biologics. The patient has failed topical therapy, phototherapy, and systemic therapy with methotrexate. 

Stelara (ustekinumab) is indicated for the treatment of adult patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy, and is therefore medically necessary in this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath; mitral regurgitation
Issue under review: Hospital transfer and admission
Summary: The hospital transfer and admission were not medically necessary.
There was no evidence of acute disease requiring a transfer to another hospital. There was no evidence of acute heart disease, acute sarcoidosis or TB. There was no documentation of any service provided at Bellevue Hospital that was not available at Queens Medical Center that the patient required.  This was a personal preference of the patient or provider to transfer to Bellevue Hospital. The patient was treated with steroids and her shortness of breath improved. She remained at Bellevue until discharge.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Myotonic dystrophy, CHF
Treatment: Inpatient admission
The proposed treatment, inpatient admission, was medically necessary.
This patient presented with decompensated congestive heart failure. Oxygen saturation was depressed even with supplemental oxygen upon presentation.  She also had concomitant myotonic dystrophy, a condition associated with an elevated risk of sudden cardiac death.  Following several days of treatment with anti-congestive therapies, she underwent prophylactic ICD implantation and was discharged.  This patient could not have been managed at an alternate level of care and required inpatient treatment/follow up. 
There have been several studies including a meta-analysis of more than 50,000 patients demonstrating poor outcomes for patients that are discharged from the emergency department after presenting with congestive heart failure.  These findings were true in both systolic and diastolic CHF. (1, 2). 
In conclusion, it was appropriate to manage this patient at an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis, past medical history included cerebral palsy, developmental delay, history of tracheostomy, and a gastrostomy tube, gastroparesis

Treatment: Inpatient admission, diagnostic testing , medication management and surgery.

The insurer denied inpatient admission. That denial was upheld.

This patient presented to the Emergency Room by ambulance due to non-bilious emesis.  The patient also had abnormal gastric distention.  The CT scan of the abdomen and pelvis revealed there was mild thickening of the entire traversing ascending colon raising a question of colitis.  There was marked distention of the rectum filled with fecal material and gas, suggestive of impacted stool.  An appendicolith was noted at the base of the appendix.  The appendix was distended with fluid and measured up to 9 mm transverse.  The findings were suspicious for early appendicitis.  The patient's white blood cell count was 9.2.  The patient underwent treatment with intravenous fluids.  The patient was admitted and gastrostomy tube feedings were held.  The diagnoses for admission included appendicitis, colitis, and partial bowel obstruction with possible surgical intervention.  The patient underwent a laparoscopic appendectomy.  The patient's feedings were started slowly after surgical intervention and she was discharged in stable condition.  The patient was to be treated with three days of Bactrim for possible urinary tract infection.

The Milliman Care Guidelines (MCG) ambulatory status is appropriate for most children with acute uncomplicated non-perforated appendicitis, and those undergoing interval appendectomy after non-operative treatment. Inpatient stays are recommended for children with complicated appendicitis (eg, perforated without generalized peritonitis) or those requiring prolonged (eg, more than 24 hours postoperatively) care after surgery (eg, co-morbid illness).  The guidelines also indicate that an exception for ambulatory surgery would include patients in need of an emergent procedure.

The patient records supported that that there were no complications from the surgical procedure.  This is regular acute appendicitis, uncomplicated by perforation, peritoneal abscess or any documented intraoperative features that would require an inpatient level of care.  The patient has CP but no one documents any issues that needed inpatient management.  There were no pulmonary or GI issues that complicated recovery and in fact the physician certified that all normal activities could be undertaken within 72 hours from discharge. Her tracheostomy status, tube fed status, non-verbal status was not documented by any practitioner at any time as requiring a special level of care.  Perhaps the sole exception was being sedated for a CT scan which was actually facilitated by the trach, not hampered because of it. The inpatient hospital admission was not considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This patient presented to the emergency department (ED) after having a near syncopal episode. He has a past medical history of coronary artery disease and a status post percutaneous coronary intervention x4 in 1999. He also has a past medical history which includes hypertension, elevated cholesterol and cigarette smoking. A report in the chart describes an electrocardiogram (EKG) done at 14:41 which showed sinus bradycardia with frequent multifocal premature ventricular contractions. Q waves in the inferior leads and T-wave inversion suggest inferior infarction-age undetermined, no serial comparisons are made. The report of an EKG done at 08:41, shows sinus rhythm at 59 beats per minute (bpm) with premature ventricular contractions and Q waves in the inferior leads as noted previously. There is no significant change from the previous EKG. Troponins done at 15:02, 15:46 and 19:19 were within normal limits. Pro- b-type natriuretic peptide was moderately elevated at 293. Chest x-ray done showed no focal consolidation. The impression was no evidence of acute cardiopulmonary disease. A head/brain Computed Tomography (CT) without contrast showed no CT evidence of acute intracranial pathology. No comparison studies are available. The patient had a transthoracic echocardiogram performed which showed mildly increased left ventricular (LV) wall thickness and mildly decreased LV systolic function with an estimated left ventricular ejection fraction of 45%. In the ED he was initially noted to be bradycardic at 40 bpm and slightly hypotensive to the 90s, but on repeat vital signs in the trauma room his heart rate was 50-60 and blood pressure in the 120s systolic. The patients home medications include lovaza, amlodipine, hydrochlorothiazide, metoprolol, Ramipril, Percocet, Crestor and Colace. A note describing the hospital course states that he was admitted for vasovagal syncope. 

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

This patient presented to the ED after an episode of near syncope. A consultant cardiologist pointed out that the patient had not eaten all day and was working outside in the heat. There was no family history of syncope or sudden death. Troponins x3 were within normal limits and his EKGs reported no change. The patient did not describe any chest pain, shortness of breath or palpitations. Other studies which included a chest x-ray and a CT of the brain were within normal limits. Review of the patients record indicates that he did not have any factors of concern listed under the San Francisco Syncope Rule. The literature cited shows that this patient did not have any alarming findings that would place him at increased risk. Based on the literature inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, Crohn's disease

Treatment: Inpatient admission, diagnostic testing, and medication management

The insurer denied inpatient admission. The denial was upheld.

The patient presented with two to three days of abdominal pain in the setting of poor response to chronic biologic therapy, a steroid taper and clinical concern for constipation. Her pain was 9/10 in intensity. An abdominal examination revealed an abdomen that was soft, not tender, with no masses or organomegaly, and no rebound tenderness. The differential diagnoses included Crohn's flare vs Infectious Gastroenteritis vs Constipation, vs Urinary Tract Infection (UTI).  Imaging showed stool burden and she was able to advance her diet following intravenous (IV) ranitidine and laxative therapy.

Regarding the left-shift which this child demonstrated on complete blood cell (CBC) count, leukocytosis and a differential lack sensitivity and specificity in predicting infectious and inflammatory disease.(4)

In terms of constipation, characteristics of children with constipation requiring inpatient management include chronicity of the disorder, overflow incontinence, and developmental delay(5), none of which describe the patient in question. Based upon the documentation provided, it appears that once the patient's constipation was addressed, her abdominal pain improved and she was discharged home.

There is no documentation that the patient in question received adequate trials of management of the suspected illness (constipation) in the emergency department prior to admission.  There was no evidence of severe dehydration/lack of response to fluid resuscitation, and there was little concern for an Irritable Bowel Disease (IBD) flare.
Appeal type: Experimental/Investigational
Decision: Overturned in Part

The patient is a male with a history of nonvalvular atrial fibrillation, liver cirrhosis, and esophageal varices. He is currently on Xarelto. Transcatheter closure of the left atrial appendage and inpatient admission are under review. The health plan's determination is overturned in part. Left atrial appendage closure in the setting of this case is more beneficial than any standard treatment options as the only alternative is anticoagulation which is contraindicated in this case. Left atrial appendage closure can be accomplished in the outpatient setting, compared to an inpatient admission, without an increased risk of complications. An inpatient admission for left atrial appendage closure has not been established as standard of care towards improved procedural outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Experimental/Investigational
Decision: Overturned in Part

The patient is a man with non-valvular atrial fibrillation, non-alcohol related cirrhosis with esophageal varices, and diabetes. He is at high risk of bleeding. A cardiac computed tomography (CT) and echocardiogram did not show left atrial appendage (LAA) thrombus. In this circumstance, it has been concluded by a non-implanting physician that implantation of a left atrial appendage occluder (LAAO) would be a preferable approach to continuing Xaralto to prevent a stroke. The issue under review is whether the requested procedure is likely to be more beneficial than standard treatment(s). The health plan's determination is overturned in part.  The procedure, LAAO with the Watchman is appropriate in this patient as described above but full admission is not.
Appeal type: Experimental/Investigational
Decision: Overturned in Part

This is a patient with a history of nonvalvular atrial fibrillation, hypertension, diabetes, liver cirrhosis, esophageal varies and prior gastrointestinal (GI) bleeding who was referred for transcatheter left atrial appendage occlusion as part of stroke prevention given elevated risk for bleeding with anticoagulation. The health plan's determination is overturned in whole. The patient has atrial fibrillation with comorbid conditions of hypertension and diabetes. Based on his stroke risk, anticoagulation is indicated. He is also at an elevated risk of bleeding given his hypertension, prior bleeding events and liver disease. As his stroke risk warrants therapy, and his is sufficiently his, non-pharmacologic approaches to stroke prevention are warranted. The Watchman left atrial appendage occlusion device is an Food and Drug Administration (FDA) approved therapy for this indication, and compared to anticoagulation, it has been shown to be similarly effective in stroke prevention and safer with regard to bleeding. In this case, transcatheter left atrial appendage occlusion is the most appropriate therapy for this patient with atrial fibrillation, elevated stroke risk and a contraindication to long term anticoagulation. This is an inpatient procedure.