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

This patient has a past medical history significant for hypertension, hypertensive kidney disease, chronic end-stage renal disease, and atrial fibrillation. The patient currently goes to dialysis 3 times a week.
The patient requested personal-care service hours 10 hours a day 4 days a week and eight hours a day 3 days a week for a total of 64 hours a week. The Uniform Assessment System (UAS) New York   noted that the patient is alert and aware of surroundings. There is no noted significant change in the patient's functional condition. Uniform Assessment System also noted a total of 2160 personal-care service minutes per week were necessary. On the report it was noted that the patient was able to ambulate with a roller walker independently. Patient was independent with eating and mobility in bed. Patient needed assistance with personal hygiene. There were no noted falls or hospitalizations. There was no noted significant dementia. It was also noted that the patient required a total of 36 hours a week. The patient is currently receiving 40 hours per week. The hours provided are adequate to meet the patient's medical needs. No additional services are medically necessary. The health plan's determination is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

The patient is of pediatric age who complains of bilateral foot pain.Paitent has bilateral flexible flat feet. Treatment recommendations include physical therapy and a prescription for University of California-Berkeley Lab (UCBL) orthoses to support the feet. At issue is whether the UCBL orthosis should be considered medically necessary.  The UCBL orthosis should be considered medically necessary in this patient. Flexible flat feet are common and often asymptomatic. This patient has flat feet associated with pain. When a flexible flat foot is severe ("severe pronation" as described by her physical therapist) and painful, orthotics to support the foot may be used to try to reduce the pain. Custom orthotics such as the UCBL orthosis are often needed in order to provide adequate support and comfort. The health plan determination is overturned in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Abdominal pain, nausea/vomiting, withdrawal symptoms
 
Treatment:  Inpatient admission, IV fluids, medications, monitoring

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

This patient presented to the Emergency Department with temperature of 97.7, a heart rate of 106, respirations 20, and blood pressure 150/88.  The patient complained of pain to left upper abdomen and chest, headache, dizziness and tremors.  Pain was a 7/10.  The patient has a history of alcohol abuse; drinks every day; last drink was two hours prior.  The patient has a history of gastroesophageal reflux disease and a known mass in the pancreas.  The patient stated that he tried to stop drinking earlier that week, started to vomit, and had alcohol.  The patient previously utilized cocaine and marijuana.  On examination, there was diffuse tenderness to the abdomen and left upper quadrant.  CT of the abdomen showed a pancreatic cystic mass that had increased from prior imaging.  The patient was admitted for antiemetics and intravenous (IV) fluids. 

The medical literature indicates inpatient admission is indicated for patients with withdrawal signs related to alcohol, sedative or opioid with high risk indicators as indicated by signs of withdrawal, nausea or vomiting, tremor, increased perspiration or other signs of alcohol or sedative withdrawal, elevated risk due to historical or comorbid factors.  The patient was seen for abdominal pain, nausea and vomiting.
Appeal type: Medical necessity
Decision: Overturned

This is a case of a patient with diagnosis of prostate cancer, for which patient has undergone radiotherapy followed by chemotherapy with leuprolide and Zytiga and maintained on prednisone 5 mg daily.  Patient also has a history of alcoholism and prior history of IV drug abuse.  Patient presented to the emergency department on 3/31/2019 with fatigue, generalized body weakness, loss of appetite and weight loss, nausea with nonbloody vomiting x2, polyuria polydipsia and cough.  Blood glucose in the emergency department was found to be 512 with a serum osmolality of 309.  The patient reported discontinuing his prednisone, per own volition, several days prior to presentation.  Urinalysis showed positive ketones, sodium level was 129, anion gap was 20, creatinine was elevated at 1.8.  The patient was admitted to the medical Intensive Care Unit (ICU), for treatment of diabetic ketoacidosis, acute kidney injury, pseudohyponatremia, nausea and vomiting.  The patient was given 1 Liter of intravenous (IV) normal saline bolus, 17 units of subcutaneous insulin, and started on an insulin drip.  The patient was also given a high dose of IV corticosteroids, due to concern for adrenal insufficiency related to poor compliance with prednisone.  Blood glucose improved down to 216, anion gap closed at 13, bicarb improved to 23.  The patient was transitioned off of the insulin drip, and transitioned to both long-acting and short acting insulin, with an endocrinology consult requested.  His diet was advanced.  Creatinine also improved down to 1.14.  The requested health service and treatment is medically necessary at an inpatient level of care.  It is the standard of care for this patient population to admit into an intensive care unit setting and treat with an insulin infusion, every hour Accu-Cheks, frequent reassessment of electrolytes and renal function, and aggressive IV fluids.  This cannot be accomplished under observation status, even if the anion gap closes within 24 hours.  A significant amount of resources need to be deployed to safely transition the patient off of an insulin infusion, including monitoring of insulin requirement and determining the best regiment of treatment.  The patient in this situation is at risk for cardiac arrhythmias, further end-organ damage, and cerebral edema, all of which could result in death.   It is the standard of care to admit these patients under inpatient status in an intensive care unit setting, as was the case with this patient.  The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department with cough, runny nose, and fever for the past two days. The patient reported pain with coughing. Vital signs on arrival to the ED were temperature 36.9C, heart rate (HR) 118, respiratory rate (RR) 20, and oxygen (O2) saturation of 96% on room air. The ED physical exam notes that the patient is active, well-appearing, and playing video games. All body systems, including pulmonary, head, eyes, ears, nose, throat (HEENT), neck/lymphatic were reportedly normal on examination. Complete blood count (CBC), comprehensive metabolic panel (CMP), and urinalysis were performed and were all normal. A chest x-ray was performed at maternal request and showed a right lower lobe interstitial opacity consistent with pneumonia. Additional testing revealed Influenza A. The child was started on intravenous fluids (IVF), ceftriaxone, and Tamiflu. He was admitted to the hospital for further management. During the hospitalization the patient was noted to have fevers to 102.9 F, appearing dehydrated with dry cracked lips. The health plan's determination is upheld.

The requested inpatient hospitalization was not considered medically necessary. Based on the medical documentation provided, this patient could have been treated at lower level of care. According to the medical documentation provided, this patient presented with stable vital signs and normal physical exam findings. The patient was noted to have fevers and cough, found to have Influenza A with pneumonia. There were no indications of laboratory abnormalities, vomiting or diarrhea, or inability to tolerate oral intake. Therefore, this patient could have safely been treated and cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of hypertension (HTN), coronary artery disease (CAD), previous myocardial infarction in 2018, alcohol, cocaine and tobacco abuse, who presented with chest pain. Pain was 10/10 in severity and increased with deep inspiration. The patient had used cocaine the day before admission. Toxicology screen was positive for alcohol and cocaine. The blood pressure (BP) was 130/92 mm Hg and pulse 85 beats per minute (bpm). Troponin was negative at 0.01. An electrocardiogram (EKG) showed anterior T wave inversion.

The health plan's determination is upheld. The patient presented with chest pain, but was hemodynamically stable. His initial EKG, although abnormal, was not diagnostic of an acute myocardial infarction (MI). His initial cardiac biomarkers were negative. The patient was stable during the hospitalization. He was admitted over a weekend, and this may have accounted for the delay in service. A lower level of care would have been more appropriate.
Appeal type: Medical necessity
Decision: Overturned

The patient  was admitted for an acute inpatient level of care for worsening symptoms of depression and suicidal ideation, as well as self-harming behavior. The patient presented with a history of major depressive disorder. At the time of presentation, the patient was tearful with hopelessness, multiple failed trials of medications .The patient worsened with increasing symptoms of depression including hopelessness, helplessness and worthlessness. Diagnosis included major depressive disorder and severe deterioration in functioning that included suicidal ideation and self-harm. The health plans determination of medical necessity is overturned in whole.The patient's continued Acute Inpatient Mental Health Treatment was clinically appropriate, reasonable, and in the best interest of the patient. The patient  had severe symptoms of depression,  was a safety risk, and, outpatient treatment had failed to prevent the worsening symptoms of depression with the onset of severe symptoms in the context of medication tolerability problems and deterioration in functioning and self-harming behavior.
Appeal type: Medical necessity
Decision: Upheld

This patient had  no significant past medical history who presented with vomiting and diarrhea for one day. The patient had 10 episodes of emesis. On physical examination the patient was described as in no distress with tachycardia. The  laboratory studies were unremarkable. 
the health plans determination is upheld in whole.The inpatient hospital admission is not medically necessary for this patient.. The  laboratory and radiological findings were unremarkable.The patient did not have any further emesis after admission to the hospital.   Findings suggested the patient would most likely stabilize and a determination concerning admission would be reasonably expected within 48 hours. The patient  was discharged in less than 24 hours. The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

This patient underwent successful elective and non-emergent stenting without complications and was monitored for an adequate post procedure period. There were no vascular complications, acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, cerebral vascular accidents (CVAs), severe bleeding, renal failure, need for urgent revascularization, need for prolonged intravenous medications or oxygen support, or introduction of high risk medications requiring prolonged in-hospital monitoring.  This setting of inpatient level hospitalization, compared to for example observation or outpatient, has not been established as standard of care towards percutaneous catheterization or overall cardiac outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal bleeding
Treatment: Inpatient admission
The inpatient admission was not appropriate and medically necessary. 

The patient presented with a one-day history of GI bleeding (hematochezia) associated with lightheadedness due to mild hypotension due to acute blood loss and hypovolemia. The hypotension was readily corrected with one liter of normal saline bolus. His Hb (hemoglobin)/HCT remained stable throughout his hospital stay, and he did not require any blood transfusion. The mild hypokalemia was corrected with IV K supplements. He was evaluated by surgery and underwent colonoscopy the next day that revealed pan-diverticulosis and no evidence of active bleeding. The patient remained hemodynamically stable, and he tolerated the diet well. He had no recurrence of hematochezia and was discharged home on 01/18/2019. Given this clinical scenario, the patient could have been safely and appropriately managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Chest pain
 
Treatment:  Inpatient admission, monitoring, diagnostic testing

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

This patient had a past medical history notable for diabetes mellitus, hypertension, hyperlipidemia, valvular disorder, and hernia repair.  He presented to the Emergency Room (ER) with complaints of chest pain and shortness of breath for the previous three days.  He had been at his Cardiologist's office, and had attempted to complete a stress test, which was not achievable due to symptoms.  On arrival, his pain was 5/10 in intensity.  EKG showed sinus rhythm and non-specific T-wave abnormality.  His troponin was unremarkable and non-diagnostic for acute myocardial infarction.  He was admitted and evaluated by cardiology. He was referred for coronary angiography, which noted non-obstructive coronary artery disease involving the right coronary artery. 

Though the cardiac biomarkers and EKG were not diagnostic of an acute event, and there was no clinical evidence of ongoing ischemia, the patient's care could not have safely been provided under observational level of care.  Per MCG Guideline Angina RRG: M-40-RRG (ISC), the patient had suspected acute coronary syndrome based on symptoms and/or anginal-equivalent, with additional high-risk findings.  This included intent to perform coronary angiography with intent to perform revascularization, as well as his history of diabetes mellitus.  Based on these findings, acute inpatient admission was medically necessary for this patient. 

The carrier's denial of coverage for the inpatient hospital services is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Asthma
Issue under review:  Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient's acute issue at the time of hospitalization was asthma exacerbation with acute respiratory care requiring mechanical ventilation.  This can only be treated in an intensive care unit.  Once extubated, the patient remained on non-invasive ventilation and unable to keep oral intake due to nausea and vomiting.  This resolved, and the patient was able to tolerate oral intake.  The acute inpatient care for entire admission is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Appendicitis
Treatment:  Inpatient admission
The inpatient admission was not medically necessary.
The operative report describes a straightforward procedure less than one hour in duration.  The findings were acute non-perforated appendicitis.  Postoperatively, the patient was ordered for regular diet.  She was observed overnight.  That evening and into the following morning, the patient had issues with pain control and vomiting.  Medications were given, which controlled the symptoms. 
By the evening of the day after admission, the patient's pain was controlled, and she was tolerating diet.  She did not complain of nausea.  The patient was converted to acute inpatient level of care in the morning of that day rather than continuation of observation.  The patient did not require acute inpatient level of care.  Continuation of observation level of care would have been appropriate.  The conversion to acute inpatient level of care was premature.  The care the patient would have received at a lower level of care would have been identical to that which she received.  The most appropriate level of care for treatment of non-perforated acute uncomplicated appendicitis is ambulatory.  Generally accepted practice guidelines for treatment of acute appendicitis without perforation in pediatric population is the procedure is considered outpatient with a period observation in some cases.  The care does not require acute inpatient level of care.  
The patient would have received identical care at a lower level of care.  The lower level of care would not have adversely affected the quality of care delivered or endangered the patient's health or safety and would not have compromised the best interests of the child.
Appendectomy for non-perforated appendicitis is considered ambulatory.  Laparoscopic appendectomy for non-perforated appendicitis can safely be performed as outpatient with or without overnight observation.  The patient underwent a straightforward laparoscopic procedure for uncomplicated appendicitis.  The literature uniformly considers appendectomy for non-perforated appendicitis in adults as an outpatient procedure.  The same standards would apply to children/adolescents undergoing appendectomy for non-perforated appendicitis.
The acute inpatient level of care would not have changed the care the patient received postoperatively, and the alternative outpatient (observation level of care) would not have adversely affected the health outcome for this adolescent patient.  The anticipated length of stay following appendectomy in a pediatric patient is less than 24 hours.  Acute inpatient level of care is not the appropriate level of care for this diagnosis, procedure or this patient's care.  The care the patient would have received at a lower level of care would have been identical to that which she received in fact.  It is in excess of the level of care which is necessary to provide safe postoperative treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, nausea, vomiting and diarrhea 
Treatment: Inpatient admission

The Inpatient admission was not appropriate and medically necessary.

Summary:

The patient was admitted with one-day history of abdominal pain, nausea, vomiting and diarrhea after having eaten at McDonald's the night before. She also admitted to smoking marijuana, and she tested positive for marijuana. In the ED, she was hemodynamically stable and afebrile. Her abdominal examination was benign, and the CT scan of the abdomen and pelvis was essentially unremarkable and did not show any intraabdominal pathology such as bowel obstruction, appendicitis, perforation, cholecystitis, pancreatitis obstructive uropathy. Over the next 48 hours, she was managed symptomatically with IV fluids, antiemetics, and acid reducers. She did not require any endoscopic or surgical intervention. She was discharged home with possible diagnosis of gastroenteritis or cannabinoid hyperemesis syndrome. In view of this clinical course, the patient could have been safely managed under lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.   

This is a female patient who presented to the emergency department after being hit in her abdomen by three students. It was reported that she was 34.4 weeks gestation. It was reported that the patient had experienced mild contractions. The patient was treated with intravenous fluids, antibiotics, Magnesium and Betamethasone. The patient and fetus were monitored by external monitoring. 

Anatomic and physiologic changes related to pregnancy impact the evaluation and management of pregnant trauma patients. The first step in evaluating such patients is to rule out a life threatening problem. Once catastrophic trauma has been excluded, the physician should determine whether the patient has any obstetric complications (e.g., abruption, uterine rupture, feto-maternal hemorrhage, preterm labor, premature rupture of membranes). The majority of women who develop adverse obstetrical outcomes have symptoms such as contractions, vaginal bleeding, or abdominal pain upon initial presentation. In pregnancies that have reached the stage of fetal viability, continuous rather than intermittent fetal and uterine monitoring is recommended for at least four hours after even mild abdominal trauma to look for signs of preterm labor and abruption.  Monitoring is discontinued after a minimum of four hours in women with uterine contractions less frequent than 1 in 10 minutes, absence of vaginal bleeding, absence of abdominal pain, and a normal fetal heart rate tracing. 

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

The patient is a young female who presented for shaking episodes at home. As per video taken on her mother's phone, she had two separate times of stiffening followed by shaking. They were tonic-clonic movements, seizures, with return to baseline. Per the emergency department documentation, during this time, as per mom, she had been taking her seizure medication regularly. There is no strong family history of seizure epilepsy. No recent trauma, fever, chills or falls. Examination in the emergency room revealed stable vital signs and she was described as well-developed and well nourished. She was active with a strong cry in no distress. The emergency room physician contacted pediatric neurology and their recommendation was to admit the child, load with Keppra, order an electroencephalogram (EEG) and magnetic resonance imaging (MRI) scan for breakthrough seizures. Of note, the patient was admitted the month prior with new onset seizure, and she was discharged home on Keppra. Apparently, her mother was giving Keppra only once a day instead of twice a day.

The patient was admitted to the pediatric floor and Keppra was started as ordered by neurology twice a day. The following day the patient was kept nothing by mouth (NPO) in preparation for the MRI and EEG, which she had done in the late afternoon. She returned to the pediatric floor in stable condition with normal vital signs and feeding well by mouth (PO). She was observed for 4 hours post anesthesia and cleared for discharge home. The MRI of the brain was normal. The patient did not have any further seizure activity while admitted. 

The health plan denied the inpatient admission as not medically necessary. The health plan's determination is upheld. 

The patient presented with breakthrough seizures that appeared to be due to under dosing of her anti-epileptic medication. She received a loading dose of her medication in the ER and did not have any further seizure activity after admission. She was described as active and in no distress by ER physician. The RN who admitted her to the pediatric floor described her as alert and awake. She did not require any highly skilled or technical care while in-house. She resumed her home medications without incident. She was hospitalized for less than 48 hours. After stabilization in the ER, there were no findings that would suggest this patient would experience further deterioration in her condition. She could have been treated at a lower level of care.