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

Abdominal Pain
Inpatient Hospital

The patient is a female. She was admitted to the hospital. She has a past medical history of gastritis. She presented with abdominal pain, nausea and vomiting that started the night prior. Vital signs showed a blood pressure of 107/74, pulse 90, respiratory rate 16 and temperature 98.5. Oxygen saturation was 99% on room air. Labs showed a white blood cell count of 15.3, hemoglobin 12.8, platelets 259, sodium 138, potassium 3.7, creatinine 0.9 and glucose 128. Lipase was 21. Liver function tests were normal. A computed tomography (CT) abdomen showed no evidence of gallstones, but gallbladder wall thickening was present. She was given Zofran, Pepcid, intravenous fluids and admitted for further management.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient presented with abdominal pain, nausea and vomiting that started the night prior. She was afebrile and hemodynamically stable. Labs showed normal creatinine, lipase and liver function tests but she did have leukocytosis. A CT abdomen showed no evidence of gallstones but gallbladder wall thickening was present. No surgical interventions were recommended by surgery. She was conservatively managed with fluids, anti-emetics, pain medications and antibiotics with improvement in symptoms.
The patient's severity of illness upon presentation did not necessitate an intensity of service for inpatient admission. Based on the review of the medical record, this patient could've been safely evaluated and treated with all medically necessary interventions provided at a lower level of care. There was no acute renal failure, severe electrolyte derangements, suspected severe infection, severe abdominal tenderness, toxic megacolon, need for surgical intervention, persistent and severe vomiting or pain.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cannabis toxicity.

Treatment: inpatient admission.

The insurer denied coverage for inpatient admission. The denial is upheld.

This patient is a male child with no pertinent history presented to the Emergency Department (ED) for complaints of altered mental status and persistent nausea and vomiting.  In the ED, the patient continued to vomit.  The initial exam showed gcs 8 TO 10, elevated heart rate of 122 beats per minute.  The initial treatment and management includes placing a non-rebreather mask, intravenous fluid bolus, intravenous ondansetron, and blood works.  

The patient was admitted for continued monitoring and work-up. Toxicology and social worker were consulted.  The hospital course of treatment and management includes placing a nonrebreather mask, intravenous fluids, intravenous ondansetron, and neuro checks every 2 hours.  The GCS gradually improved as expected.  No more labs needed and no perturbations in the clinical status.  The patient continued to be hemodynamically stable throughout the hospital course. The patient was cleared for discharge to home.

The patient did not have persistent low Glasgow Coma Scale (GCS), the GCS improved quickly.  The peds ED did not intubate the child because they were confident that the expectant clinical course did not warrant securing the airway.  Also there was no acidosis or respiratory acidosis (ph < 7.25), the ph was 7.38 so it was reassuring.  Moreover, the blood pressure (BP) was normal and heart rate (HR) 122 was not concerning for the patient's age. 

In a systematic review where they examined the cannabis toxicity in 114 children, there was no mortality.  The most common ingestion (n = 43, 38%) was cannabis resin, followed by cookies and joints (both n = 15, 13%).  Other exposures included passive smoke, medical cannabis, candies, beverages, and hemp oil. Lethargy was the most common presenting sign (n = 81, 71%) followed by ataxia (n = 16, 14%).  Tachycardia, mydriasis, and hypotonia were also commonly observed.  All cases were cared for in the Emergency Department or admitted, and mean length of stay was 27.1  27.0 hours.  Twenty (18%) were admitted to the pediatric intensive care unit, and 7 (6%) were intubated. 

In this child it might have been gummies laced with beta agonists, and the initial toxicity was short-lived and child improved quickly.  Hence, acute impatient level of care is not medically necessary.  The patient could have been in observational status with continuous pulse oximetry. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis:  Rule out tuberculosis.

Treatment:  Inpatient hospital stay. 

The insurer denied coverage for inpatient hospital stay.  The denial is upheld.

This patient is a female with a history of asthma.  She presented to the Emergency Department (ED) for follow up of an abnormal computed tomography (CT) scan of the chest.  The patient had the CT scan of the chest done in the outpatient setting, and it revealed some opacities in the right upper lobe.  Differential diagnoses included infectious process / rule out tuberculosis.  The patient received a course of Azithromycin for her cough.  When the patient presented to the ED, she denied hemoptysis, weight loss, or night sweats.  Vital signs at presentation included a temperature of 98, a heart rate of 82, a blood pressure of 122/70 mm Hg, a respiratory rate of 14, and an oxygen saturation of 99%.  The patient was in no acute distress and her lungs were clear.  A repeat chest CT scan revealed a right upper lobe calcified granuloma and some calcification in the right hilar and mediastinal nodes consistent with an old granulomatous disease.  Also described was a tree-in-bud appearance which was suspicious for reactivation of tuberculosis.  

The patient had a negative QuantiFERON-TB in 2017.  It was decided to admit the patient and place her on airborne isolation to rule out tuberculosis (TB).  This patient was afebrile and hemodynamically stable.  Oxygen saturations were 100%.  The physical exam was unremarkable.  Her white blood cell count was 12.1K, and her hematocrit was 38.8.  Electrolytes were within normal limits.  The patient remained stable after admission and was afebrile and hemodynamically stable.  She was tolerating oral intake.  The patient had 2 samples sent for acid fast bacilli (AFB), both of which came back negative.  The patient decided to sign out against medical advice.

This patient did not need acute inpatient hospitalization.  She could have been placed in observation status while sputum smears for AFB were obtained.  Sputum smears for AFB can be obtained 8 hours apart, and once negative the patient could have been discharged home the next day after a period of observation with close follow up in the outpatient setting.  The patient did not receive any care for which acute inpatient hospitalization was needed.  She only had 2 samples of sputum collected.  This did not require acute hospitalization and could have easily been done in the observation setting.

The prior denial is upheld.  The insurer acted reasonably, with sound medical judgement, and in the patient's best interest.

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

Diagnosis: Possible chromosome abnormalities 

Treatment: Genetic testing (Chromosomal Microarray [CMA])

The insurer denied coverage for genetic testing (Chromosomal Microarray [CMA]). The denial is overturned.

This patient is a female born full-term by C-section for fetal heart decelerations and breech presentation with a birth weight of 6 pounds 13 ounces. Although appearing normal at birth she subsequently developed hypotonia, developmental delays (motor > intellectual), progressive dysphagia status post gastrostomy/jejunostomy tube placement, gastric dysmotility, strabismus and hypoglycemia status post PICC line placement for total parenteral nutrition.

A summary of her assessments to date is as follows:
1.	MRI of the brain and spine - negative
2.	EEG - no seizure activity
3.	EMG - normal by report
4.	Chromosome analysis for fragile X - negative
5.	Arginase analysis - normal
6.	Audiology testing - normal
7.	Karyotyping - questionable deletion of the long arm of chromosome 12 (q21.31q21.32).Her current medications include Neurontin, nortriptyline, glycopyrrolate, Zofran and simethicone.

This patient suffers from progressive neuromuscular impairment and developmental delay without a diagnosis. Her assessments to date have failed to yield a diagnosis with the only abnormal finding being a karyotype suggesting a deletion of the long arm of chromosome 12. A reference to deletions of the long-arm of chromosome 12 can be found at the Genetic and Rare Diseases Information Center and states the following: Chromosome 12q deletion is a chromosome abnormality that occurs when there is a missing copy of the genetic material located on the long arm (q) of chromosome 12. The severity of the condition and the signs and symptoms depend on the size and location of the deletion and which genes are involved. Features that often occur in people with chromosome 12q deletion include developmental delay, intellectual disability, behavioral problems, and distinctive facial features. Most cases are not inherited, but people can pass the deletion on to their children. Treatment is based on the signs and symptoms present in each person.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for genetic testing (Chromosomal Microarray [CMA]) is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastroparesis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a female with history of anxiety/depression (managed with Zoloft, bupropion, trazodone, Ambien), Grave's disease (S/P [status post] radiation treatment, on Synthroid), chronic analgesic requirements for pain. Pertinent to this review, the patient has longstanding gastroparesis. She has failed to optimally benefit from various motility agents, as well as implantation of gastric pacemaker.  

The patient underwent outpatient EGD (esophagogastroduodenoscopy) with performance of gastric per oral endoscopic myotomy (G-POEM procedure). She was thereafter admitted for management of "10/10" abdominal pain, IV (intravenous) PPI (proton pump inhibitor) therapy, and IVF (intravenous fluids). NPO (nothing by mouth) was initiated, with intention for the patient to undergo an UGI (upper gastrointestinal) series the following morning to assess for leaks. 

Throughout her hospital stay, the patient exhibited tachycardia and elevated blood pressure, in the setting of anemia (hemoglobin 10) and ongoing IV hydromorphone requirements for pain management, IV Zofran for anti-nausea, and IV PPI. Vital signs, diet, and medications administered are summarized per supplied case summary.

Yes, the inpatient admission was medically necessary.

The patient's post-procedure hospitalization was medically appropriate for pain management and to exclude a post-procedure operative complication.

Gastroparesis is a chronic and debilitating disorder with an incompletely understood complex pathophysiology, yet treatment options are limited. Only metoclopramide is FDA-indicated for this disabling condition. Interventionally, compared with surgical pyloroplasty, G-POEM is a minimally invasive endoscopic procedure that potentially provides shorter lengths of hospital stays and good patient tolerance. In early trials, clinical response rate determined by symptomatic improvement following G-POEM reached 73 to 86 percent after up to 12 months of follow-up. (1,3-5) 

Pertinent to this review, the overall complication rate of G-POEM reaches 6.7 percent, including gastrointestinal bleeding, pyloric ulcer and tension capnoperitoneum. Per Cai (6), G-POEM "is a technically challenging procedure compared with esophageal peroral endoscopic myotomy due to antral contractions, curved submucosal tunnel, extensive vascularity and a very thin duodenal wall, which predisposes patients to a high risk of perforation." 

The health plan approved coverage for the surgery. A full hospital admission is medically necessary if there are severe problems during or after surgery. These might include bleeding, infection, or uncontrolled pain. As such, the patient's post-procedure hospitalization was medically necessary, as necessitated in large part for her post-op pain management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mild pancreatitis.

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission. The denial is upheld. 

This patient is a male who presented with abdominal pain. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The lipase was 41. A CAT scan revealed inflammation around the hand of the pancreas. He was treated with IV hydration and pain medications. A consult done on a specified date found no abdominal tenderness.
Clinical indications for admission for Pancreatitis include having 2 or more of the following: abdominal pain pancreatitis enzymes, greater than 3 times the upper limit of normal and characteristic findings on abdominal pain had already improved by the time of admission. The impression was that he had a mild pancreatitis. Other indications include evidence of infection, severe pain, hemodynamic instability, hypoxemia, acute renal failure, and severe electrolyte abnormalities. The patient did not have these conditions.

This patient had a mild pancreatitis that had already improved by the time of admission. IV hydration and pain medications could have been given with observation status. He did not have any complications from pancreatitis and remained stable. The healthcare plan acted reasonably and with sound medical judgement. An inpatient hospitalization was not medically necessary.

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

Diagnosis: Respiratory system /COPD 
Treatment: Home health care 

The insurer denied increase in consumer directed personal assistance program services: 12 hours per day 7 days per week; 12 hours per day 7 days per week (split shift) for a total of 168 hours per week. The denial is overturned in whole.  

The patient with past medical history of oxygen dependent end-stage chronic obstructive pulmonary disease (COPD) on hospice since 05/13/20 and dementia who had previously been assigned Consumer Directed Personal Assistance Services (CDPAS ) 12 hours/day, 7 days/week to total 84 hours per week. 

Yes, consumer directed personal assistance program service hours 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split-shift) for a total of 168 hours per week are medically necessary for this patient. 

The patient had significant change in assistance need with multiple tasks due to worsening of end -stage COPD. The patient was placed on hospice due to worsening functional status and has had a rapid decline in function which will only continue to worsen as the patient progresses to end of life. The patient lives with spouse who is not able to provide informal help any longer. The patient has multiple needs overnight that would not allow a live-in CDPAS to have 5 hours of uninterrupted sleep during their 8-hour period of sleep. The patient's CDPAS is not solely for supervision and safety as the patient requires total assistance with tasks of toilet use (and walking/locomotion but patient bed bound since 5/22/20 phone assessment) which occurs overnight at unpredictable times.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lung infection
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a female whose inpatient admission is under review. The patient has a history of asthma, HTN (hypertension), and sleep apnea/CPAP, who presented with a fever and sore throat for one day plus weakness (unable to ambulate). No cough or dyspnea.

The patient was thought to have sepsis versus pneumonia, started on IV vancomycin and levofloxacin. She improved after a few days and was discharged home on po (oral) levofloxacin.

Yes, the inpatient admission is medically necessary.

The patient presented with worrisome signs and symptoms of a severe infection, including the following:
1) Fever
2) Leucocytosis
3) Bandemia
4) Hypotension
5) Elevated anion gap
6) Lactic acidosis
7) Tachypnea

It was thought that she could have pneumonia versus sepsis. Her pneumonia severity score (PSI/PORT) is 71, which means she could be treated as an inpatient or outpatient, depending on clinical judgment (1). She also met SIRS (systemic inflammatory response system) criteria. Standard of care would require admission of such a patient. Failure to admit could lead to respiratory failure, organ dysfunction/failure, shock, and death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male who presented for inpatient rehabilitation treatment to address substance use disorder with opioid (heroin), stimulant (cocaine), cannabis (marijuana) and sedative-hypnotic-anxiolytic (Xanax) use disorder. The patient was tobacco dependent. Substance use began in adolescence and progressed as a young adult to daily continuous use of heroin as his drug of choice with up to ten bags daily and ongoing use of $10-$20 worth of cocaine one to two times per week, regular use of Xanax 2-4 mg/day and an unspecified amount of marijuana. The patient had no past history of withdrawal seizures or delirium tremens or other episodes severe withdrawal symptoms. Past attempts at substance use disorder treatment had failed to result in sustained abstinence or engagement in a recovery process though he reported up to a month of abstinence and had participated in 12-step meetings with a sponsor. He stopped going to recovery meetings and lost contact with his sponsor with a relapse. The patient's substance use was associated with ongoing stressors that included the primary support and legal and social environment domains with an arrest for grand larceny, and, an environment that was drug infested and replete with substances of abuse. The admission and self-referral for inpatient level detoxification treatment had occurred with transition to rehabilitation substance use disorder treatment. 

The patient did not require the structure or monitoring of an inpatient setting in order to address the issues related to relapse, or to receive safe and effective substance use disorder treatment. There were no biomedical or psychiatric issues that would have required inpatient level structure, monitoring or services, as noted in the answer to question 3 below.  Additionally, the requested inpatient admission is not consistent with prevailing standards of professional practice, or consistent with published practice guidelines (best practice) or the ASAM Criteria, referenced below, and NY State OASAS LOCADTR Guidelines did not support the medical necessity for treatment at an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

No, the proposed inpatient admission is not "medically necessary".

The patient is a male with a past medical history significant for HTN (hypertension), DM (diabetes mellitus), Atrial fibrillation, systolic dysfunction, with EF of 35-40% on prior echo, and anxiety, who presented to the ED for evaluation of syncope episode, which occurred after urination, associated with sweating. No chest pain or focal neurological deficits. The patient was hemodynamically stable. ECG revealed no acute ischemic changes. The head CT done in the ED was negative for acute bleed or CVA (cerebrovascular accident). Chest X-ray was unremarkable. The physical examination was normal. Troponin was negative. 

The patient was admitted to telemetry for monitoring. He was diagnosed with likely vasovagal syncope and the plan for repeat echocardiogram and carotid Doppler; however, the patient did not want to stay in the hospital for further work-up and requested to be discharged. The patient was advised to follow-up with his cardiologist as outpatient.

The patient presented with an episode of syncope, consistent with a vasovagal event. He was hemodynamically stable. There was no evidence of an acute myocardial infarction, unstable angina, decompensated CHF (congestive heart failure), acute CVA (cerebrovascular accident), intracranial bleeding or seizure. Although it was prudent to observe the patient and rule out cardiac or neurological pathology prior to discharge, there was no evidence of an acute cardiac or neurological condition requiring an inpatient admission. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at an observational level of care.