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

Respiratory System
Inpatient Hospital

Diagnosis: Asthma
Treatment: Inpatient admission

The health plan denied: Inpatient admission
The determination is: Overturned

The patient is a former premature female infant who presented with cough, congestion, and difficulty breathing. She was well until 2 days prior to presentation when she developed a cough and congestion. She was drinking less than usual and then subsequently developed difficulty breathing. She had decreased wet diapers and decreased activity. Her mother also reported hearing wheezing at home. She was subsequently brought to the emergency department for evaluation.

Upon presentation she was found to have tachypnea with a respiratory rate of 60 breaths per minute. She was noted to be in mild respiratory distress with intercostal retractions. She also developed a fever up to 100.7 Fahrenheit (F). She received an albuterol nebulized treatment but continued to have respiratory distress. She was therefore admitted to the hospital for further care.

In the hospital she was treated with ipratropium, methylprednisolone, and albuterol every 2 hours. She was found to have rhinovirus/enterovirus infection. She improved over time, and began tolerating every 4 hour albuterol treatments and was stable on room air. She was felt to be stable for discharge to home with follow up as an outpatient.

At issue is the medical necessity of the inpatient hospital stay.

The health plan's determination of medical necessity is overturned in whole.
Yes, the requested health service/treatment of inpatient hospital stay was medically necessary for this patient.
The patient is a young infant who presented with respiratory distress secondary to a viral infection and reactive airways disease. She continued to have respiratory distress after appropriate treatment with bronchodilators in the emergency department setting. She required hospital admission for intensive treatments, initially with bronchodilators every 2 hours, as well as corticosteroids and monitoring with additional treatments as needed.
Children with respiratory distress who require bronchodilator treatment more often than every 4 hours require hospital admission for continued intensive treatments. This patient initially required albuterol every 2 hours as well as intravenous solumedrol and close monitoring in an inpatient setting.
The decision making at the time of admission for this patient was consistent with her young age, the presence of respiratory distress and tachypnea that required continued intensive treatments, and the need for close monitoring for the potential deterioration of her clinical status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obsessive Compulsive Disorder. 
Treatment: Continued Residential Mental Health Treatment. 

The insurer denied Continued Residential Mental Health Treatment. 
The determination is overturned. 

This is a female patient who was diagnosed with severe obsessive-compulsive disorder (OCD); skin picking disorder with excoriation; social anxiety disorder (social phobia); illness anxiety (hypochondriasis); and an unspecified depressive disorder.
She was referred and admitted for residential psychiatric treatment. Despite treatments in the community, the patient continued to have severe symptoms of anxiety, compulsive rituals, and intrusive thoughts and, she had a significant decline in functioning such in that he was unable to function socially or occupationally, or at times had been unable to do basic self-care. 
The patient was making progress with achievement of 75 percent (%) of her goals and participating in intensive treatment. She continued to struggle with symptoms related to anxiety and OCD with prominent compulsive rituals, skin picking in the bathroom, and a continued lack of skills and insight. At times, the patient was resistant to participating due to the severity of her symptoms and persistently impaired functioning; she required ongoing monitoring and coaching with regard the therapy (DBT, CBT, ERP, Life Skills), as well efforts to address social phobia, agoraphobia, and illness anxiety. 

The requested health service/treatment of psychiatric residential treatment was medically necessary for this patient. 

The patient's admission and continued residential level treatment is reasonable and warranted. She continued to display severe symptoms of obsessive-compulsive disorder (OCD) and associated symptoms of anxiety together with distress problems, interpersonal functioning problems and decline or impairment of functioning that had deteriorated to the point that she was unable to benefit from treatment at lower levels of care. She continued to display coping deficits and a lack of insight that did warrant the structure, monitoring, and intensity of treatment for the duration of the residential stay. The patient could not be effectively managed at a lower level of care in a less restrictive treatment setting during the time interval under review.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures

Treatment: Inpatient admission

The insurer denied coverage for Inpatient admission

The denial is upheld
 

This is an adult female who presented with complaints of seizures. The patient complained of having seizures while sleeping. The current seizure regimen was documented as Keppra 500 milligrams (mg) twice daily, topiramate 25 mg for two weeks, and then twice daily. The patient's neurologist advised that she would require electroencephalogram (EEG) monitoring. A head computerized tomography (CT) scan performed on presentation was negative for any acute changes. The patient was admitted to an acute level of care. During the patient's hospitalization, there was no documentation that she had any additional treatment or testing other than a routine EEG, not prolonged EEG testing.

The patient underwent a routine electroencephalogram (EEG) that was unremarkable but did not undergo extensive video electroencephalogram (EEG) testing prior to discharge. 

This is a patient who had breakthrough seizures and was on a low therapeutic dose of Keppra and a subtherapeutic dose of topiramate. The patient could have had her seizure stabilized in the emergency department with an extra Keppra load, an increase in topiramate dose or an initiation of a third antiepileptic medication. Once the patient received additional antiepileptic therapies and had no recurrent seizures, she could be safely discharged from the emergency department or observation. There were no acute inpatient needs. The patient did not have any hemodynamic instability, cardiac abnormalities, or respiratory abnormalities. The patient was no longer having external seizures. The patient had no change in mental status, suspicious of subclinical seizures. Note that electroencephalogram (EEG) monitoring would not have been of assistance. The patient had a known seizure disorder, and a negative electroencephalogram (EEG) will not rule out the fact that she had breakthrough seizures. Once the patient received the appropriate loading dose of an antiepileptic medication, she could have been safely discharged in the emergency department or from observation. The patient could have been discharged without the need for an inpatient admission. The patient did not require any neurological monitoring, hemodynamic monitoring, or cardiac monitoring or any other level of acute care and had a normal neurological and mental status and neurological examination at the time of presentation, and as detailed above, did not specifically require electroencephalogram (EEG) monitoring. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is the case of an adult female who presented to the emergency department (ED). As per the ED provider note this was a patient status post (s/p) gastric sleeve, Gastroesophageal reflux disease (GERD) like symptoms in the past who presented with right upper quadrant (RUQ) pain for the past 3 days. She denied urinary symptoms.  Exam revealed the abdomen to be soft, diffusely tender in the mid and RUQ. The plan was to evaluate for gallstones. She was afebrile with stable vital signs. Studies revealed a gall bladder with thickened walls and gall stones. She was admitted with the diagnosis of cholelithiasis. Surgery was to be consulted. White Blood Cell (WBC) count was 12.74. Liver function tests (LFT's) were normal. 

She was taken to the operating room and underwent a robotic assisted cholecystectomy.  Surgery was uneventful. Surgery started at 14:07 and was completed by 15:50. Path revealed chronic cholecystitis with cholesterolosis and cholelithiasis. 

Post operatively she had no complications. She tolerated the pain and tolerated a general diet. She was discharged to home.

Based upon the records, the acute inpatient admission from was not justified as this patient could have been managed in an ambulatory/observation setting as she had an uneventful lap cholecystectomy for biliary colic and possibly acute cholecystitis. She could have been managed as noted by the insurer in an ambulatory/observation setting as she had an uneventful laparoscopic cholecystectomy for cholelithiasis/acute cholecystitis. She did not have acute cholangitis and she was not septic. She did not have a significantly elevated WBC and she did not have a fever. She did not have elevated liver function tests. She did have a cholecystectomy, but this could have been done in an ambulatory/observation setting without an acute inpatient admission.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cervical spine disease

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 

This is an adult female with cervical spine disease. She underwent anterior cervical disc fusion (ACDF) cervical (C) 4-6. Upon completion of the operation she had a drain placed. Her physician recommended to monitor drain output and if satisfactory to remove drain and discharge home. The records showed continued drainage with high output. The physician now recommended continued monitoring for hematoma and admission. 
The medical records document a post surgical complication. This type of procedure is complex and extensive. The physician placed a drain to prevent hematoma. The physician documented continued drainage which is not common. Anterior cervical discectomy is performed bloodless with infrequent use of a drain. The report of continued drainage is of concern. The possibility of hematoma is real. Compression of soft tissue structures can cause a catastrophic complication, (i.e. airway compromise). Any concern about increased drainage and need to maintain this two days after surgery should be of concern. The admission for monitoring is essential. No other level of service would be considered. As concluded by Epstein  "In our review of 11 studies focused on anterior cervical surgery, the incidence of postoperative hematomas ranged from 0.4 to 1.2%. Early recognition of these postoperative hemorrhages, and appropriate management (surgical/non-surgical) are critical to optimize recovery, and limit morbidity, and mortality."
Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for a full hospital admission to Mount Sinai South Hospital is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Polycystic ovary syndrome 
Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a female with a history of Polycystic ovary syndrome (PCOS), prior sleeve gastrectomy, and nephrolithiasis presented with 1dayof right-sided abdominal pain, nausea, and vomiting. In the emergency department (ED) her temperature was 98.5, blood pressure (BP) 133/53, heart rate (HR) 49-61, respiratory rate (RR) 18 and her peripheral capillary oxygen saturation (SpO2) was 99 percent (%) on room air (RA). She was in no distress; her heart rate was bradycardic. She was breathing comfortably with clear lungs. Her abdomen was soft and non-distended and without guarding and she was alert and oriented. 
The white blood cell count (WBC) was 12.7, sodium 140, bicarbonate 25.6, blood urea nitrogen (BUN)/creatinine15/0.9 and her fibrin degradation product (d-dimer) was 2.14. The urinalysis (UA) showed moderate blood, moderate leukocyte esterase. The computed tomography pulmonary angiogram (CTPA) with no pulmonary embolism (PE). The computed tomography (CT) of the abdomen and pelvis showed no obvious nephrolithiasis or hydronephrosis. During her ED stay, her pain improved markedly, and she was felt to have passed a kidney stone. For elevated troponin (Tn), repeat testing was ordered and cardiology consulted.
She was seen by the cardiologist who felt that this was unlikely to be acute coronary syndrome and recommended discharge if repeat Tn remained below 1-2. The Tn was repeated, remained minimally elevated (below cardiology's cut-off described above), and she was discharged with outpatient follow-up.

The inpatient admission was not medically necessary. She presented with abdominal pain and was diagnosed with a kidney stone which was felt to have passed during her ED stay with improvement in pain. With no evidence of urinary tract obstruction (no hydronephrosis) and no concern for sepsis, she did not need any intervention and did not require an inpatient stay for inpatient only testing, monitoring or treatment. This can be managed on an outpatient or observation basis. She also had an elevated Tn with no chest pain, an unremarkable CTPA (with no PE, dissection, pneumonia, etc.), and an unremarkable electrocardiogram (ECG), and the cardiology evaluation felt her symptoms and elevated Tn were not concerning. An observation admission would have been reasonable to ensure pain was controlled and to ensure Tn elevation did not significantly worsen. However, as there was no concern for urinary tract obstruction, sepsis, or an acute cardiac issue, an inpatient admission was not needed. She did not meet any of the provided criteria for inpatient admission.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

The patient had morbid obesity and presented with diarrhea and abdominal pain. She developed a fever of 103.5. While in the emergency room (ER) the patient was afebrile, and the vital signs were stable. There was no abdominal rebound or guarding. An abdominal computed axial tomography (CAT) scan was negative for acute disease. The initial white blood count (WBC) count was 16.6 but on repeat was 11.06. The patient was diagnosed with acute gastroenteritis. Intravenous (IV) hydration and antibiotics were given. The symptoms improved and the patient was switched to oral antibiotics. 

Medical necessity was determined using Milliman Care Guidelines (MCG) guideline M-170 for Gastroenteritis. Clinical indications for admission include having a suspected severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had a gastroenteritis. IV hydration and antibiotics could have been given in the ER with observation care. Afterwards, the patient could have been discharged on a course of oral antibiotics. The patient's symptoms improved with treatment. The patient did not meet MCG criteria for admission for Gastroenteritis. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Otitis media

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This was a patient who presented with fever and decreased intake and pulling of the left ear for 3 days. The patient's temperature was 101 Fahrenheit (F) at home. About 1 month ago the patient had an ear infection in the left ear that was initially treated with amoxicillin, and then with Augmentin. Mother stated the patient was otherwise acting normally.

On exam in the emergency room (ER) the patient is described as active and not in acute distress, and not toxic-appearing. The only abnormal finding on exam was bilaterally erythematous tympanic membranes (TM), with the left TM bulging with some blood. 

The admission justification states that the patient had otitis media refractory to outpatient treatment and decreased intake and urinary output. However, there is no objective evidence of dehydration documented anywhere in the chart. In fact the blood urea nitrogen (BUN) was 10 which is normal. Moreover, pulling on the ear is not a sign that is specific for otitis media.

The patient likely had a viral illness with otitis media with effusion, which does not need to be treated with intravenous (IV) antibiotics (2). Contrary to the appeal language, the patient was not at risk for hearing loss in the short term.

Inpatient care was not medically necessary. The patient had no objective evidence of dehydration. The patient was not described as ill-appearing or toxic. There is no documentation of a trial of oral feedings and the medical justification for admission as stated is insufficient. A better course of management would have been a trial of oral intake in the emergency room. Even if we assess the patient as having mild dehydration, per current literature on management of dehydration in children, and using the Children's Hospital of Pennsylvania (CHOP) pathway, a trial of oral rehydration following a bolus of IV fluids should be done, especially as there were no ongoing losses (there was no ongoing vomiting or diarrhea).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Digestive system
Inpatient hospital

Diagnosis: abdominal pain
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a male with medical history of gastroesophageal reflux disease (GERD), hypertension, obesity, and benign prostatic hyperplasia. He presented to the emergency department with severe cramping abdominal pain radiating to the back, and abdominal distention. Vital signs were notable for elevated blood pressure of 160/109. Physical examination was notable for right upper quadrant tenderness and abdominal distention. Labs showed unremarkable complete blood count and elevated bilirubin of 1.9. He was treated with intravenous fluids, ciprofloxacin metronidazole, clindamycin, and ketorolac. He was made nil per os (NPO). 

The inpatient level of care was not medically necessary.
The patient presented with symptoms and imaging consistent with cholecystitis. However, he did not have evidence of ascending cholangitis, gallstone pancreatitis, hepatic abscess, active gastrointestinal bleeding, peritonitis, or sepsis, which would require a higher level of care. Additionally, there was no persistent hemodynamic instability or other complications. The patient did have an uncomplicated cholecystectomy soon after presentation, and did not experience postoperative complications such as pneumonia, sepsis, or bile leak which might require the inpatient level of care. There was no contraindication to performance of imaging and then cholecystectomy after presentation. His liver enzymes were elevated, but there was no acute liver failure, choledocholithiasis, or other concerns resulting in additional intervention. The interventions performed, including labs, monitoring, imaging, and cholecystectomy, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease

Treatment: Consumer Directed Personal Assistance Program (CDPAP); 12 hour per day- 7 days per week- a total of 84 hours per week

The insurer denied coverage for Consumer Directed Personal Assistance Program (CDPAP); 12 hour per day- 7 days per week- a total of 84 hours per week

The denial is overturned 

This is an elderly male with progressive Parkinson's disease.   He lives alone in a 1-bedroom apartment.  The plan approved Consumer Directed Personal Assistance Program (CDPAP) 6 hours/day - 7 days/week - for a total of 42 hours and the request is for 12 hours/day- 7 days/week- for a total of 84 hours/week.

The Uniform Assessment System (UAS) report was reviewed.  The patient's cognitive status is "Moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times."  He is reportedly totally dependent to maximal assistance for Instrumental Activities of Daily Living (IADL) tasks including shopping, ordinary housework and meal preparation.  Extensive assistance is reportedly needed for bathing, dressing, locomotion, toilet transfer/use and ambulation.  Limited assistance is reportedly needed for personal hygiene and bed mobility.  The patient reports being occasionally incontinent of bladder and continent of bowel.  

The patient's self-sufficiency and ADL (Activities of daily living) status have deteriorated and declined, respectively, over the prior 90 days.  His cognitive status and functional ability have also declined when compared to the prior UAS report.  The letter from the patient's treating neurologist discussing his underlying clinical condition and associated functional impairments was also reviewed.  However, submitting the associated clinical notes would have also been helpful.  The patient's condition, cognitive status and functional needs are at a level and unpredictable as to require the requested CDPAP 84 hours/week.

The patient may actually require additional monitoring.  However, safety monitoring under CDPAP does not include monitoring an individual (e.g., with dementia) when no other Level I or Level II personal care services task is being provided.  Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained by increasing CDPAP to 12 hours/day, 7 days/week, totaling 84 hours/week.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Consumer Directed Personal Assistance Program (CDPAP); 12 hour per day- 7 days per week- a total of 84 hours per week services is substantiated.