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

Diagnosis: Mental Health (Schizoaffective Disorder)
Treatment: Mental Health: Inpatient

Summary: This patient was admitted for inpatient psychiatric treatment due to psychotic symptoms including auditory and visual hallucinations derogatory in nature and reports that he was seeing shadows and visions, bizarre thoughts as he had a delusion that his body was shrinking, slowed thought process and thought blocking, disorganized thoughts, uncooperative behavior, urges to hurt self, poor activities of daily living (ADL's), impaired judgment and insight, poor impulse control, sad and irritable mood. He had a diagnosis of Schizoaffective Disorder with multiple past and recent psychiatric hospitalizations. He was living in a shelter and was unemployed. He refused medications at times including Haldol and was switched to Prolixin. He was discharged with follow-up referral for outpatient psychiatric treatment.

The insurer has denied coverage for the continued inpatient psychiatric hospital treatment as not medically necessary treatment. The denial was modified.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports 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. The denial was partially approved because the patient still had psychotic symptoms during the denial period including internal preoccupation, agitation, poor hygiene, impulse control, and insight. He was at risk of decompensation of psychotic symptoms, so he still needed 24 hour hospital treatment then. The subsequent days of the admission were denied because he did not have reports of significant psychotic symptoms requiring continued 24 hour hospital treatment. Notes reported he denied feelings of depression, suicidal ideation, auditory or visual hallucinations. Notes reported that he denied harmful thoughts to self or others and denied perceptual changes. Notes reported that he denied suicidal or homicidal ideation, hearing voice or seeing things not there though he reported hearing music, and it was reported that his thoughts were more logical, mood was calmer, and insight was improving. Notes reported that he had euthymic mood and no suicidal or homicidal ideation and he was discharged. There were no reports of significant psychotic symptoms, suicidal or homicidal ideation, aggressive, self-injurious, or severely agitated behavior, manic or major depressive episodes, acute medical instability, severe withdrawal symptoms, or inability to adequately care for his basic needs.  Also, there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24 hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting then.  Approval of 1/25/19. Denial of 1/26/19-1/29/19.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain and vomiting, history of end-stage renal disease on dialysis, hypertension, coronary artery disease, non ST elevated myocardial infarction (NSTEMI), status post stent placement, pancreatic mass, ascites, Bell's Palsy and immunocompromised status

Treatment: Inpatient admission, diagnostic evaluation, hemodialysis, and medication management

The insurer denied inpatient hospital admission. That denial was upheld

This patient presented to the hospital Emergency Room with subjective complaints of epigastric, abdominal pain x4 days, with occasional vomiting.  The patient missed her last hemodialysis and was due on the date of arrival.  The patient's laboratory studies included a red blood cell count (RBC) of 2.61, hemoglobin of 8.1, hematocrit of 25.3, potassium of 6.7, a blood urea nitrogen (BUN) of 121 and a creatinine of 10.4.  The patient had undergone an EKG which revealed sinus arrhythmia and prolonged QTc.  The patient's troponin was 0.02 and her blood natriuretic peptide (BNP) was greater than 5000.  The patient was admitted to telemetry for monitoring.  The patient received emergency dialysis.  The patient underwent consultations with renal, cardiology, gastroenterology, infectious disease, and underwent a surgical and vascular consultations.  The patient's potassium stabilized with the emergency dialysis that was provided.  The patient underwent a fistulogram and angioplasty of the left upper extremity.  The patient was subsequently stabilized and discharged.

Admission is appropriate for patients with clinically significant electrolyte abnormality that requires inpatient care such as hyperkalemia that was due on the date of presentation.  The patient had subjective complaints with severe ECG findings.  Alternatives include outpatient initiation and maintenance of hemodialysis or peritoneal dialysis.  The guidelines indicate that observation is appropriate for patients who have uremic complications not adequately treated by outpatient or emergency department such as dialysis is needed due to nausea or vomiting or significant metabolic abnormalities such as severe acidosis or hyperkalemia.  

The patient was found to have hyperkalemia and underwent dialysis.  After the dialysis, the hyperkalemia stabilized.  The patient could have undergone the fistulogram and angioplasty on an ambulatory basis, which would not require hospitalization. The guidelines support that observation was appropriate. The patient could have been treated at a lower level of care, including observation.  If the patient required admission, the patient could have been admitted after a failure of observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral respiratory infection
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
This very young child presented to the ED with signs and symptoms consistent with acute viral infection, including fever, cough, and congestion. Rapid viral testing revealed positive influenza A. Chest x-ray was consistent with bronchiolitis. While it was not unreasonable to monitor her for increasing respiratory symptoms or poor oral intake, she was overall hemodynamically stable, with no oxygen requirement and no evidence of secondary bacterial infection. She did not require acute inpatient management and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Asthma and pneumonia
Treatment: Inpatient Hospital Admission

Summary: This patient with a history of asthma and one previous admission for asthma was sick for 3 days with a runny nose and a cough. The patients mother had been administering albuterol via a nebulizer in the home with some improvement in the cough. The patient developed a fever and worsening respiratory distress and the mother brought the child to the emergency room (ER) for further treatment. In the ER the patient was noted to be in mild respiratory distress with evidence of increased work of breathing. The pulse oximeter reading was not low. The patient received a dose of DuoNeb. A chest x-ray demonstrated pneumonia in the right middle lobe. The patient was then given a dose of ceftriaxone and a bolus of intravenous saline. On physical exam the patient was noted to appear comfortable and alert with mild respiratory distress with bilateral wheezing. The decision was made to admit the patient with a diagnosis of asthma and pneumonia for ongoing treatment with albuterol every 4 hours and ipratropium every 6 hours. 

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.
 
The patient was treated in the ER with one dose of DuoNeb. The evidence of pneumonia on a chest x-ray impacted the decision to admit the patient to the hospital. The standard treatment for status asthmaticus consists of three back to back treatments with bronchodilators over an hour. Since the patient was comfortable with only mild distress there was a good chance for the patients asthma to respond to appropriate treatment and he could then have been safely discharged on an oral antibiotic and albuterol every 4 hours with a follow up visit with a pediatrician in 24  48 hours. The patient was not treated with back to back bronchodilators and the delay of 5 hours till the next administration of albuterol was not consistent with the standard of care for asthma in child of this age. The possible pneumonia in the right middle lobe could have been treated with oral antibiotics. Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath, chest tightness
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
Based on the records submitted for review, on the date of the admission, the vital signs reported by triage did document that the patient had acute respiratory distress thought to be due to acute on chronic hypercarbic respiratory failure due to asthma exacerbation.  It should be noted that the data reported in the appeal letter was a venous blood gas suggesting that the arterial numbers would be in within the normal range, as the patient was placed initially on the BiPAP to help reduce the work of the breathing.  The patient met criteria for observation for the first day; all the other dates did not meet medical necessity criteria for inpatient hospital stay.  Throughout these dates, the patient's vital signs had been stable.  She had no respiratory distress; the respiratory rate per the nursing note and the physician data had been less than 20, the oxygen saturations on two to three liters nasal cannula had been in the upper 90s.  The patient had been ambulatory, and had been sitting on the chair daily anywhere from two to three hours.  There were no issues with appetite; she was using the bathroom without any issue.  The patient was refusing the BiPAP.  There was no deterioration reported throughout this hospitalization requiring significant nursing care or acute care.  The CT scan performed documenting the consolidation of the left lower lobe and then followed up by another CT scan on 02/02/2019 were not medically indicated as the patient's clinical condition did not show any deterioration requiring these evaluations.  In addition these consolidation or parenchymal changes did not affect the patient's clinical condition as she was on minimum oxygen; when she was hospitalized she was placed on two to three liters nasal cannula.  She had no issues with the sensorium.  Therefore the patient did not meet the medical necessity criteria for continued inpatient stay . During these days, she did not require or have any of the following:- continued respiratory distress requiring frequent respiratory therapies or noninvasive ventilation - hemodynamics compromise requiring management of the hemodynamics such as using fluid resuscitation or blood pressure support medications. There was no clinical condition suggested that patient had a heart attack, stroke or any life-threatening condition during this hospitalization. On the day of the admission, the patient did meet the criteria for acute asthma exacerbation, but it was not severe enough to require acute inpatient management.  The patient's venous blood gases suggested the patient arterial blood gases were compensated.  Therefore acute respiratory failure was an inappropriate diagnosis due to acute asthma exacerbation, which reversed within 24 hours of acute intervention.  Further continued hospital stay was not supported by the documentation provided.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, sickle cell crisis
Treatment: Inpatient Hospital Services

Summary: This patient had sickle cell disease and presented with abdominal pain and diffuse body aches. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. Gallstones were noted in the gallbladder and in the common bile duct (CBD). There was no sonographic evidence of cholecystitis. There was leukocytosis. Pain medications were given. The patient eloped from the hospital.

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

Clinical indications for admission for gallbladder or bile duct inflammation or stone are listed in Milliman Care Guidelines (MCG) M-555. These indications include acute cholecystitis as manifested by right upper quadrant pain and a systemic sign of inflammation. In this case, the patient had gallstones but did not have signs of acute cholecystitis. The patient also had a CBD stone but did not have evidence of acute cholangitis. She also did not have evidence of severe vomiting, severe dehydration bacteremia, or hemodynamic instability. She had normal renal function. Clinical indications for admission for sickle cell disease MCG M-331 include having an acute central nervous system injury, acute chest syndrome, severe hypoxemia, need for emergency surgery, acute renal failure, and altered mental status. The patient did not have these conditions. She required pain medications but they could have been given with observational status. The patient had sickle cell disease and gallbladder disease. The sickle cell disease could have been managed with intravenous (IV) hydration and pain control with observation care. The gallbladder disease did not require any acute surgical intervention at this time. She was stable to have had an outpatient endoscopic retrograde cholangiopancreatography (ERCP). There was no evidence of acute cholecystitis or cholangitis at this time. The patient did not meet MCG Criteria for admission for either gallbladder disease or sickle cell disease.
Appeal type: Medical necessity
Decision: Upheld

This patient presented five days post- cesarean section with complaint of left lower abdominal pain, chills, malaise and fever of 101.2F at home.  She also reported chest congestion, cough and rhinorrhea x2 days.  Vitals were stable.  The temperature was 99.2 F.  Abdominal and vaginal examinations were negative.  White blood counts were 9.4. The patient was admitted with the diagnosis of rule out post-partum endometritis and upper respiratory tract infection versus pneumonia and was started on intravenous antibiotics. A chest x-ray revealed left upper lobe pneumonia, and Infectious Diseases was consulted.  The patient was switched to oral Amoxicillin-Clavulanate, and she was discharged home in stable condition.

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

This patient presented with signs of upper respiratory infection later diagnosed as pneumonia and concern about post-partum endometritis. Post-partum endometritis is a common cause of postpartum febrile morbidity (defined as an oral temperature of 100.4 degrees Fahrenheit or more).  The infection is polymicrobial, usually involving a mixture of two to three aerobes and anaerobes from the lower genital tract. The diagnosis of postpartum endometritis is based upon clinical criteria of fever and uterine tenderness occurring in a postpartum woman.  Other signs and symptoms which support the diagnosis include foul lochia, chills, and lower abdominal pain.  This patient does not fulfill the above criteria.  As per admission note, the patient was afebrile and abdominal and vaginal examinations were normal.
Appeal type: Medical necessity
Decision: Overturned

The patient presented to the hospital with abdominal pain. The patient rated the pain as an 8/10. Stating that it ran across her mid-abdominal area, non-radiating, no alleviating factors. The abdominal pain was made worse by coughing and bearing down. 

The health plan's determination is overturned. The inpatient stay was medically necessary. Per Milliman Care Guidelines (MCG) clinical admission indicators, patients whose evaluation requires them to not eat or drink for greater than 24 hours should be admitted to an inpatient acute care setting. For the dates of service in question the patient at hand was kept NPO for both symptom control and plans for a procedure to occur throughout her stay more than a total of 24 hours. In addition, patients suffering with severe pain requiring acute inpatient management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Inpatient Hospital

Summary: This patient was brought to the Emergency Department (ED) with heavy vaginal bleeding, weakness, shortness of breath and dizziness. She has a past medical history of vaginal bleeding and anemia status post myomectomy in 2018. Lab results revealed hemoglobin of 5.1. The patient was transfused with 2 units of packed red blood cells and was admitted to the medical unit. Her hemoglobin improved to 7.7. She was seen by gynecology and pelvic sonogram showed 2 small fibroids. The patient was given Premarin 25mg x 3 doses and discharged home in a stable condition on oral Levora.

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

This patient was actively bleeding, 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. However, 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 received 2 units.  She was also given intravenous (IV) estrogen. High-dose IV estrogen is beneficial in women with acute uterine bleeding. IV estrogen results in cessation of bleeding in most women within five hours of the first dose. Based on the above, this patient could have been monitored for a few hours in the ED, her complete blood count (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.
Appeal type: Medical necessity
Decision: Overturned

This patient was sent to the emergency department by his cardiologist because of an abnormal electrocardiogram (EKG) with a plan for a left heart catheterization. The patient has a history of hypertension, end-stage renal disease (on hemodialysis), anemia secondary to end-stage renal disease, chronic gastrointestinal bleed, recent methicillin-susceptible Staphylococcus aureus bacteremia with infectious endocarditis and severe aortic regurgitation. He was recently hospitalized and a transesophageal echocardiogram at that time showed no vegetation but the patient was discharged on intravenous antibiotics to complete a six-week course for presumed infectious endocarditis. The long-range plan included left heart catheterization and cardiothoracic surgery for possible aortic valve replacement. The patient was found to have an upper lung cavity lesion, which was negative for tuberculosis and thought to be possibly due to septic emboli. A left heart catheterization was performed and showed no evidence of coronary artery obstructive disease.

The insurer denied coverage for the inpatient hospital services as not medically necessary. The denial was reversed.

This patient had bacterial endocarditis and was receiving antibiotic therapy prior to aortic valve replacement for severe aortic regurgitation. The issue being discussed is whether or not he needed hospital admission and EKG monitoring because of concern of a cardiac abscess. His cardiologist was concerned about this complication because of a prolonged PR interval and at least one reported episode of Mobitz type I second-degree atrioventricular block. The literature that has been cited indicates that myocardial abscess is not a common complication for patients with endocarditis, but it is a complication that carries a very high mortality. The literature cited shows that it is not always easy to diagnose and if the diagnosis is made too late the patient may have already developed severe consequences or have died. Because this complication is rare and extremely serious, this reviewer agrees that it is reasonable to act in the best interests of the patient by monitoring him as closely and carefully as possible. Because of these factors inpatient admission was medically necessary. It should be noted that his needed aortic valve replacement took place during this period of time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine headaches
Treatment: Ajovy
The proposed treatment with Ajovy is not medically necessary.
There are no high quality clinical trials or standard of care guidelines supporting the safety and efficacy of Ajovy when used as an adjuvant to Botox.  The clinical trial leading to the FDA approval of Ajovy excluded persons who were actively treated with Botox at study commencement. Therefore, the safety and efficacy of Ajovy and an adjuvant to Botox remains undetermined.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal (Back pain)
Treatment: Inpatient Hospital 

Summary: This patient with a past medical history of spine surgery five years ago was seen in the Emergency Department (ED) due to back pain, nausea and vomiting. Pain was noted to be a 7/10. He had pain that radiated to the bilateral lower extremities. He had vomited six times the previous night and when vomiting felt something pop in his back and ever since had back pain. On examination, there was decreased range of motion to the bilateral lower extremities. There was decreased range of motion on flexion extension to the back with point tenderness over the L5. Straight leg raise was not completed due to pain. There was decreased strength at 2/5 in the bilateral lower extremities. This was symmetric and the patient stated this was due to pain. A magnetic resonance imaging (MRI) scan revealed L4-5 mild degenerative anterior spondylolisthesis and posterior spondylosis of the endplates. A progress note noted pain was a 6/10. The patient had decreased range of motion on examination. Vomiting had resolved. The patient was receiving morphine for pain management. A subsequent progress note noted that the patient reported improvement in pain when at rest but exacerbated by attempting to ambulate. Pain was a 5/10. Another progress note noted that the patient reported improvement in pain control with no overnight events. The patient was then discharged home.

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

The medical literature indicates that inpatient admission is indicated for patients with back pain if there is evidence of cauda equina or conus medullaris syndrome, progressive or severe neurological deficit, spine fracture with significant damage or threat of damage to the vertebral column or spinal cord, suspected spinal infection, suspected cause that requires inpatient treatment or severe pain requiring acute inpatient management. This may be indicated if the pain control regimen for the next level of care is not established after observational care as indicated by sufficient pain control not achieved; or regimen used to achieve sufficient control is not readily performed mobile at the next level of care. The patient required multiple pain medications in the ED including ketorolac intravenous (IV) push, Zofran IV push, oral methocarbamol and oral Tylenol, morphine sulfate IV push, lidocaine, and fentanyl IV push. Following admission, the patient then required continued IV morphine every 4 hours until the day of discharge. The patient was not able to ambulate without severe pain until the day of discharge. The patient did have severe pain requiring acute inpatient management. The pain control regimen for the next level care was not established after observational care as there was not sufficient pain control achieved. Therefore, the inpatient hospital services were medically necessary.