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

Diagnosis: Acute exacerbation of asthma

Treatment: Hospital admission

The insurer denied coverage hospital admission. The denial was upheld.

This patient is a male who presented to the Emergency Department (ED) with complaints of worsening of shortness of breath (SOB) and wheezing for one day and cough with productive yellow sputum for four days. The patient also complained of some chest tightness. The patient did not respond to rescue inhalers at home so he went to the ED. The vital signs at presentation were temperature (T) 98.6 F., heart rate (HR) 114, blood pressure (BP) 148/91 mm Hg, respiratory rate (RR) 24 and oxygen (O2) saturations 94 % on room air. The patient was using some accessory muscles. The lung exam revealed bilateral wheeze.

The following laboratory work results were; white blood cell (WBC) count was 12.6 K.  Electrolytes were within normal limits (WNL). Venous blood gas (VBG) was 7.377/44.6/33. The chest x-ray showed no acute Infiltrates. The patient was given Prednisone 60 mg orally (PO) in the Emergency Department. He was treated with Duo Nebs, Magnesium and antibiotics. The patient continued to have some wheezing so he was admitted for treatment of acute exacerbation of asthma.

The patient was admitted and treated with intravenous (IV) steroids, bronchodilators and the antibiotic, Doxycycline.

The patient remained stable after admission. He improved quite rapidly. The repeat vital signs on a specified date were, temperature (T) 98. F, heart rate (HR) 102, respiratory rate (RR) 18, blood pressure (BP) 148/83, and oxygen (O2) saturations 99% on room air (RA). The peak expiratory flow (PEF) was 270.
The patient was tolerating fluids orally. He was medically cleared for discharge on oral antibiotics, steroids and bronchodilator with outpatient follow-up.

Based on medical documentation it appears that this patient did not need acute inpatient hospitalization. The patient did not meet Milliman Care Guidelines (MCG) Asthma (ORG: M-60). He could have been placed in Observation status while diagnostic testing and treatments were initiated. The patient was afebrile and hemodynamically stable and continued to remain so through hospital stay. The patient did not have any pneumonia or pneumothorax (PTX). The patient was not hypoxic. This patient could have been switched to oral steroids and oral antibiotics after a brief stay in Observation status. The patient was stable for discharge with instructions to follow-up in an outpatient setting. The insurer's prior denial is appropriate. The health plan acted reasonably and with sound medical judgment and in the best interest of the patient.

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

Diagnosis: Anemia
Treatment: Inpatient admission

The Inpatient admission was not medically necessary.

This patient presented to the hospital with anemia that was symptomatic but non-critical.  She had had a colonoscopy within the last five years.  She was hemodynamically stable on admission, with no signs stigmata of active bleeding.  As opposed to acute level hospitalization this could have been managed at a lower level of care with appropriate blood transfusions.  

For patients with symptomatic anemia with a Hgb of 6.0 on presentation, this is a deficit of at least six units of PRBCs.  As opposed to single multiple transfusions of PRBCs over several days, this deficit could have been corrected over a 24 hour period with three to four units of PRBCs in the first 24 hours.  Following correction of the hemoglobin, the patient was otherwise stable for discharge.  The reminder of the evaluation for CT scan etc could have been conducted as an outpatient.  If managed this way, the patient would have been discharged prior to the discharge date, when she developed an acute hospital acquired fever.  The fever was a result of delay in care as discussed above, and could have been avoided with appropriate management.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a medical history of long QT syndrome, prostate cancer, alcohol dependence, chronic pancreatitis, cerebrovascular accident, hypertension, coronary artery disease status post stent placement in 2008.  He presented to the emergency room with epigastric and periumbilical abdominal pain, vomiting, and diarrhea for 1 week.  He had emesis in the emergency department despite antiemetics.  Physical examination was notable for tremors.  The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale was 10.  Lab results were notable for a high blood alcohol level of 161 milligrams per deciliter (mg/dL) and elevated creatinine of 2.8 mg/dL.  An electrocardiogram showed a prolonged QT interval of 509 milliseconds (ms).  An x-ray of the abdomen showed a nonobstructive bowel gas pattern.  A right upper quadrant ultrasound showed hepatic steatosis.  He was treated with intravenous fluids.  He was admitted as an inpatient with telemetry.  He was started on scheduled Ativan for alcohol withdrawal.  A Cardiology consultation on the first day of admission ruled out acute coronary syndrome but recommended continuous cardiac monitoring due to a prolonged QT interval.  On the second day of admission, he had no active complaints and a CIWA score of 4.  Labs showed improvement in potassium to 1.66 millimoles per liter (mmol/L) and decline in potassium to 2.7 mmol/L.  The health plan's determination is upheld.  The patient resented with abdominal pain, nausea, vomiting, and diarrhea.  This was consistent with gastritis or gastroenteritis; however, there was no sustained tachycardia or hypotension, gastrointestinal bleeding, or acute pancreatitis, and no evidence of pathology such as gastrointestinal perforation, abscess, fistula, peritonitis, sepsis, or bowel obstruction [1-4].  The patient did not have any signs of protracted alcohol withdrawal, and CIWA score improved on benzodiazepines within a day [5,6].  Acute kidney injury was uncomplicated and improved with intravenous fluids [7].  Cardiology recommended monitoring but did not recommend intervention for long QT syndrome.  The patient had close monitoring and treatment with intravenous fluids and electrolyte repletion, which were warranted.  However, all of the measures that were undertaken, including observation for alcohol withdrawal and arrhythmia, intravenous fluids, and specialist consultations, could have been performed without an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Primary Diagnosis:  Alcohol Abuse/Addiction
Primary Treatment:  Substance Abuse: Inpatient

The patient is an adult female who was admitted following medical screening to acute inpatient level detoxification services for monitoring and detoxification and withdrawal management of severe alcohol, stimulant (cocaine), cannabis, sedative-hypnotic-anxiolytic (benzodiazepine), and opioid use disorders.  The patient was receiving methadone at a dose of 100 milligrams (mg) daily in a maintenance program.  She was using large amounts of alcohol with up to two pints of liquor per day, intermittent use of cocaine and marijuana, as well as daily use of Xanax.  The patient had experienced severe alcohol/anxiolytic and opioid withdrawal in the past and had moderately severe withdrawal at the time of admission with sweats, chills, tremors, body aches, head ache, and nausea, as well as anxiety and restlessness.  She had severe withdrawal symptoms in the past requiring detoxification including detoxification treatment in the past year with relapse.

The health plan's determination is overturned.  The Inpatient Detoxification Services were medically necessary for this patient.  The patient in this case presented with a diagnosis of severe alcohol, opioid, cannabis, sedative-hypnotic-anxiolytic and stimulant use disorders with history of severe alcohol and opioid withdrawal in the past.  She was using multiple substances of abuse despite participation in a methadone maintenance treatment program.  The patient also has severe psychosocial stressors with limited support and functional impairments.
The presenting clinical features and history and risk for withdrawal seizures and other complications of alcohol/anxiolytic and other substance use disorders did warrant the admission and the continued inpatient level services with medical monitoring in this case scenario.  The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could not have been provided at a lower level of care in this case scenario.
Appeal type: Medical necessity
Decision: Upheld

This patient has a history of Crohn`s disease. The patient did not respond well to treatment with Pentasa or Cortenema. The request is for treatment with Humira. The request was denied by the health plan because this patient has not tried/failed treatment with all the available conventional therapies and can be treated with Azathioprine (or 6-mercaptopurine).

The health plan's determination is upheld. Humira is not medically necessary for this patient. The patient has not yet tried and failed the plan's preferred medication [Azathioprine (or 6-mercaptopurine)]. The clinical practice guidelines support treating uncomplicated cases of Crohn`s disease with conventional therapy as first line therapy. Starting biologics early in the course and before trying conventional therapy can be appropriate in certain situations where patients are expected to have poor outcome. These special situations include severe pan-enteric disease, osteoporosis, marked growth retardation, fistulizing or stricturing disease (Ruemmele, F. M., et al). This patient does not have documentation indicating severe or pan-enteric disease, no evidence of fistulas or stricturing disease and no mention of osteoporosis. This patient does not have predictors of poor outcome and is a candidate for conventional therapy such as azathioprine or mercaptopurine.
Per the clinical practice guidelines for the management of Crohn`s disease in adults." Azathioprine and 6-mercaptourine are effective therapies and should be considered for treatment of patients with Crohn's disease for maintenance of remission (strong recommendation, moderate level of evidence)."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Suicidal ideation and plan

Treatment: Inpatient mental health treatment

The insurer denied coverage for inpatient mental health treatment. The denial was upheld.

This patient is a female who was admitted to inpatient mental health treatment due to suicidal ideation and plan, inability to contract for safety, anxiety, panic attacks, and depressive symptoms.  It was reported that she had a diagnosis of Major Depressive Disorder, Binge Eating Disorder, and rule out Borderline Personality Disorder.  She reportedly had Lamictal and Vyvanse discontinued and was started on Abilify.  This was her first reported hospitalization and episode of suicidal thoughts.  She reportedly had Dialectical Behavioral Therapy (DBT) treatment also.  She reportedly improved and was discharged.

The insurer denied coverage for continued inpatient mental health treatment in this hospital as not medically necessary treatment then.  

This reviewer agrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital as the medical records did not provide enough specific evidence to support that she only required this acute psychiatric hospital level of care then or that she could not be safely and effectively treated in a less restrictive level of care by then.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and that patients with suicidal plan or intent or behaviors, or inability to adequately care for basic needs are candidates for hospitalization.  She reportedly had suicidal thoughts and plan on admission as well as significant depressive symptoms and required and received 24 hour acute psychiatric hospital treatment at that time.  However, the medical records by a specified date did not report further suicidal ideation, intent, plan, or behavior.  There were no reports as of that specified date of severe depression, feelings of hopelessness, severe psychomotor retardation, inability to adequately care for basic needs, and there were no reports of self-injurious behavior.  Also, as of then 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.  

Inpatient mental health treatment at this hospital was not medically necessary.  It appeared that the health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

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

Diagnosis:  History of SAB and ectopic pregnancy
Issue under review:  Genetic testing

Determination:
The Genetic testing is not medically necessary.

The patient is an adult G6 P1041 female with history of two SAB (spontaneous abortions) and one ectopic pregnancy and no other significant medical history.  She had an NIPT (noninvasive prenatal testing) and microdeletion analysis performed as a prenatal screening test.  Of note, the patient was not AMA (advanced maternal age).  She had no prior history of parental balanced translocation or prior child with aneuploidy, no evidence presented of ultrasound finding suggestive of trisomy, and no prior screening result suggestive of elevated risk for aneuploidy.  

The appropriate choice of genetic screening tests is predicated not only on sensitivity and specificity of a given test in a given population, but also on the predictive value, which will depend on the prevalence of the disease.  The predictive value is the clinically meaningful attribute to determine the risk and benefit ratio for a patient given knowledge of her unique background risk for the disease.  At the present state of the art, while sensitivity and specificity of cell free DNA testing is similar in high and low risk populations, the much lower prevalence in low risk populations results in a much higher risk of false positive screen results in low risk populations, due to the lower positive predictive value.  This patient does not have any of the classic high risk characteristics for aneuploidy.  

Therefore, the Society for Maternal and Fetal Medicine does not recommend cell-free DNA screening for patients in this patient's risk category.  In addition, neither the American College of Obstetricians and Gynecologists nor the Society for Maternal and Fetal Medicine recommends the use of cell-free microdeletion screening, due to a lack of demonstration of clinical utility.  Therefore, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Hypertension/High Blood Pressure
Treatment:  Inpatient Hospital

The patient is a male with past medical history significant for hypertension (HTN) who presented to the emergency room (ER) with dizziness and nausea.  He denied chest pain (CP), headache (HA), shortness of breath (SOB), blurry vision, focal weakness, numbness or tingling.  He had been seen at his dentist's office and reported intermittent dizziness x3 days while walking and was noted at the office to have a blood pressure in the 200s, at which point he was referred to the emergency department (ED) for further evaluation.
On presentation, he was noted to be afebrile with blood pressure (BP) 171/106, heart rate (HR) 74, and saturating 100% on room air (RA).  Exam otherwise noted no focal neurologic deficits or other abnormalities.  Labs noted complete blood count (CBC) and basic metabolic panel (BMP) within normal limits and troponin undetectable.  Computed tomography (CT) head showed indeterminate punctate hyper attenuating density along the interhemispheric fissure adjacent to the corpus callosum of unclear significance.  EKG was not suggestive of acute ischemia or arrhythmia.  The patient was given intravenous fluids (IVF) and meclizine in the ER and was subsequently brought into the hospital with impression that he had hypertensive urgency.
The following day the patient's blood pressure was well controlled on his home medications without other acute issues, and he was subsequently deemed stable for discharge with outpatient neurosurgery follow up.
The issue in question is whether admission at the acute inpatient level of care was medically necessary.

The health plan's determination is upheld.

Acute inpatient admission was not medically necessary.
This is a patient with a history of hypertension who presented with hypertension and dizziness.  This patient presented with hypertensive urgency, given his elevated BP accompanied by dizziness, but without hypertensive emergency (no acute exam findings, laboratory abnormalities, or EKG changes suggestive of end organ damage).  His blood pressure and symptoms improved quickly, were not refractory to multiple doses of IV medications, and did not require a continuous IV infusion for control.  His head CT findings clearly represented a chronic process unrelated to his presenting symptoms and did not require further work up in the inpatient setting.  He had no other acute medical process requiring inpatient care.  There was no reason to expect on presentation that this patient would require further work-up or prolonged hospitalization.  This patient did not meet medical necessity for care at the inpatient level of care.  Inpatient stay was not medically necessary.  The patient could have been appropriately treated at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Myocarditis/pericarditis

Treatment: Inpatient admission 

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

This patient is a female with a past medical history notable for ovarian cyst, who presented to the ER with complaints of right-sided chest pain. The pain was constant and sharp, and aggravated by deep inspiration. She had stable vital signs and oxygen saturation. EKG showed normal sinus rhythm. Her troponin trended up from 0.195 to 1.290. She was admitted and evaluated by cardiology. She was diagnosed with myocarditis/pericarditis and discharged home with non-steroidal anti-inflammatory drugs.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.
 
The patient presented with chest pain. However the initial evaluation in the ER was unremarkable, including a non-diagnostic EKG. She had low probability of acute coronary syndrome with pleuritic chest pain, ultimately with the diagnosis of acute myocarditis. Left ventricular function was normal and there were no signs suggestive of heart failure or arrhythmia warranting inpatient admission. The patient's care could have been provided in the observational setting, allowing for additional cardiac testing. Further evaluation was warranted. However, inpatient admission criteria were not met.  There was no evidence of other medical conditions warranting inpatient level of admission. The observational level would have been appropriate.

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

Diagnosis: Abdominal pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient has a past medical history of gastritis and cholelithiasis. He presented for evaluation for abdominal pain. The patient underwent laparoscopic cholecystectomy with intraoperative cholangiogram without complications.

The patient presented with signs and symptoms of biliary colic without evidence of sepsis. He had normal vital signs and normal laboratory data. Operative findings were typical for an inflamed gallbladder without any untoward event. In addition, the postoperative period was as expected. 

After an uncomplicated elective laparoscopic cholecystectomy, patients can drink clear liquids once awake from anesthesia, and their diet can be advanced as tolerated.

Most otherwise healthy, reliable patients with good home support can leave the hospital within six hours after surgery. Cochrane reviews have found no significant differences for important clinical outcomes for patients discharged the same day versus admitted overnight following laparoscopic cholecystectomy. A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, which included 15,248 patients older than 65 years of age who underwent elective laparoscopic cholecystectomy, identified congestive heart failure, American Society of Anesthesiologists class 4, bleeding disorder, and renal failure requiring dialysis as significant independent predictors of inpatient admission and mortality.

The patient has no findings either pre or intraoperative the required an inpatient stay or evaluation. The care could have been rendered safely and effectively at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness, slurring
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult male with alcohol use disorder, hypertension and hyperlipidemia. He presented with the complaint of left hand weakness and slurred speech after drinking alcohol. CT of the brain and CT angiogram where without acute findings. 

There were no concerning features in the patient's history or examination at presentation to warrant acute inpatient level of care. The diagnostic studies, monitoring and treatment could have been safely and effectively completed at a lower level of care. Therefore, the Inpatient admission was not medically necessary.