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

Diagnosis: Worsening cough (Pneumonia) 
Treatment: Inpatient admission 

The insurer denied the inpatient admission. The denial is overturned. The inpatient admission was medically necessary. 

The patient is a female whose inpatient admission is under review. The patient was admitted previously with pneumonia, where she was treated with intravenous (IV) antibiotics, and discharged home on azithromycin and cefdinir. She was positive (+) for cough with sputum production (green), and positive for dyspnea. 

In the ER: Temperature (T) - 98.8, Pulse (P) - 87, Respiratory rate (RR) - 20 , Blood pressure (BP) - 140/65, Pulse oximetry - 96% on room air (dropped to 90% on room air). General - no acute distress (NAD), Chest - clear to auscultation (CTA) bilaterally, Cardiovascular system (CVS) - regular rhythm and rate (RRR), Abdomen - normal.

White blood cell (WBC) - 5.4, Hemoglobin (Hg) - 12.6, Hematocrit (Hct) - 38.1, Platelets (Plt) - 207, Sodium (Na) - 142, Potassium (K) - 3.9, Chloride (Cl) - 102, Carbon dioxide (CO2) - 28, Blood urea nitrogen (BUN) - 10, Creatinine (Cr) - 0.84.

In the ER, the patient was thought to have pneumonia with failure of outpatient therapy. She was admitted and started on intravenous (IV) vancomycin and cefepime, but she developed an adverse reaction to vancomycin. She was switched to IV levofloxacin. Symptoms and oxygenation improved over several days and she was discharged on oral (PO) levofloxacin. 

In their denial letter, to support their denial, the health plan states, "The member did not demonstrate ... hypoxemia." This is false, the patient was hypoxemic (see vital signs above above). In their denial letter, to support their denial, the health plan states. "The member did not demonstrate ... outpatient failure." This is false, as the patient failed outpatient treatment, and this was the stated reason why she was readmitted. Even by the health plan's own criteria, the patient should have been admitted. Regardless, standard of care would require admission and IV treatment of someone who failed outpatient treatment of pneumonia. Failure to do so could result in respiratory failure or death, neither of which is in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Digestive System/Gastrointestinal.
Treatment:  Inpatient Hospital.

The insurer denied the Inpatient Stay.  The denial is overturned in whole.

The patient is a male with history of major depressive disorder, who presented from the inpatient psychiatry unit with complaint of acute abdominal pain.  The pain is described as colicky in nature, started periumbilically and spread to the right lower quadrant.  Additional symptoms include fever, nausea, and anorexia, with pain rated 8 out of 10 in severity.

Vitals were temperature (T) 36.9 Celsius (C), heart rate (HR) 70, respiratory rate (RR) 22, blood pressure (BP) 92/45, O2 sat 96% on room air.  Physical exam noted right iliac fossa tenderness with guarding, positive obturator and psoas signs, and mild rigidity.  Labs showed white blood cell (WBC) count 4.8 with 60% segs and 26% lymphs, hematocrit (HCT) 43, platelets (Plt) 204; electrolytes were normal.  Influenza A testing was positive.  The patient was diagnosed with acute appendicitis with possible perforation, and mesenteric adenitis.  He was stared on oseltamivir and piperacillin-tazobactam and admitted to the inpatient unit.

A computed tomography (CT) scan of the abdomen and pelvis was performed as an inpatient and showed constipation with bladder distension; there was no evidence of acute appendicitis.  The patient was given an enema with good result and passage of both stool and urine with resolution of abdominal pain.  Tamiflu was continued for treatment of influenza and the patient was transferred back to the psychiatry unit.  At issue is the medical necessity for the inpatient stay.

The health plan's determination is overturned in whole.

This patient presented to the hospital with the acute onset of severe abdominal pain, initially periumbilical but now right lower quadrant in location.  Associated signs and symptoms included nausea, anorexia, and peritoneal signs (guarding with positive obturator and psoas signs).  Thus, this patient clinically met criteria for probable acute appendicitis with concern for rupture given the peritoneal signs and rigidity.  A surgical consultation was done with similar concern.  Thus, the patient was started on intravenous fluids (IVF) and intravenous (IV) antibiotics while awaiting further diagnostics.  As an ultrasound was not immediately available, a computed tomography (CT) scan was done which gave a definitive diagnosis of constipation and urinary retention.

An inpatient stay was appropriate given the clinical concerns and indications; inpatient level of care was essential to ensure no decompensation or surgical emergency while awaiting definitive diagnosis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes

Treatment: Inpatient admission
 
The insurer denied the inpatient admission.

The denial was overturned.

This is a female patient with no past medical history. She presented to the hospital with several weeks of polyuria and polydipsia. The patient was found to have a glucose level of 500 with a high level of ketones without acidosis. She was diagnosed with new onset diabetes and admitted for insulin initiation and dose titration, and new onset diabetes education. Prior to her admission she was treated with intravenous saline. The patient received Lantus and an insulin to carbohydrate ratio and an insulin sensitivity factor. The family received diabetes education. The patient was discharged the following day after completion of education on basic care of type I diabetes.

Diabetes education consists of several components, nutritional counseling, self-monitoring of blood glucose and treatment of hyper and hypoglycemia. The standard of care is that all patients with diabetes should receive all these components. (1, 2) 

Practice patterns differ depending on the availability of educators, etc. Whether a patient gets hospitalized for intensive insulin therapy initiation depends on the available program where the patient is seen.

The majority (75%) of medical centers in the US (3) that treat new onset type 1 diabetes admit their patients. According to the American Diabetes Association [ADA] statement on treatment of type 1 diabetes (4), hospitalization is necessary regardless of severity if, "the center is not experienced in the outpatient management of newly diagnosed children with diabetes or is not adequately staffed to provide outpatient care because regional health care reimbursement is inadequate for initial outpatient care and education."  In type 1 diabetes, the initial hospitalization is to educate the patient and the family in self-injection, drawing up and mixing of insulins, checking blood sugar, recognizing and responding to hyper and hypoglycemia, and evaluating ketosis, as well as nutrition education on carbohydrate counting because there is only one treatment option (insulin). Learning these skills is an overwhelming task for most patients and families and is the reason that this is done with a 2-3 day admission to the hospital. 

In this case, the patient had new onset type I diabetes and required insulin initiation with dose titration and full diabetes education prior to discharge. Discharge from the Emergency Room would have been considered unsafe. The denial was based on MCG. These guidelines are not consistent with the standard of care when it comes to pediatric diabetes. 

The requested acute inpatient admission is consistent with generally accepted standards of medical practice and is therefore medically necessary. The health plan did not act reasonably, or with sound medical judgement, or in the best interest of the patient. 

Based on the above, the medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trouble breathing / fluid in the lungs. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. The denial is overturned. 

Yes, the Inpatient admission is "medically necessary". 

The patient is a male at the time of admission to the hospital, with a past medical history significant for HTN (hypertension), obesity, bariatric surgery, diabetes mellitus, who presented to the ER with new onset dyspnea, progressive lower extremity edema and left-sided chest pain. The patient was hypertensive to 187/110, and had tachypnea to 27/minute. ECG revealed no acute ischemic changes. The chest X-ray revealed left pleural effusion, bilateral vascular congestion and opacities, which may represent pneumonia or atelectasis. 

The patient was admitted for management of hypertensive urgency and new onset CHF (congestive heart failure). He was treated with IV Lasix and antihypertensive therapy was intensified. His BP (blood pressure) remained elevated to 196/102 and the BP therapy was escalated with increase in hydralazine and metoprolol. Echocardiogram was obtained and the patient was found to have normal EF (ejection fraction) with evidence of diastolic dysfunction. He was diagnosed with diastolic CHF and was his BP was treated with multiple agents. He was discharged home with a plan for outpatient follow-up. 

The patient presented with symptoms of acute CHF exacerbation. His blood pressure was severely elevated, despite the therapy in the ED and with signs of acute CHF decompensation; his presentation was consistent with hypertensive urgency. He was appropriately treated with IV diuresis. He required close monitoring of his CHF, BP and titration of antihypertensive medications. Given the presentation, uncontrolled hypertension, as well as acute decompensated CHF, it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Stats post sinus surgery.
Treatment:  Post-operative nasal endoscopy with debridement after nasal surgery (e.g., septoplasty, turbinectomy).
The insurer denied the Post-operative nasal endoscopy with debridement after nasal surgery (e.g., septoplasty, turbinectomy).  The denial is overturned.

The Post-operative nasal endoscopy with debridement after nasal surgery (e.g., septoplasty, turbinectomy) was medically necessary.

The patient is a male with a history of sinus surgery, septoplasty and turbinate reduction earlier in the year.  At the patient visit, the patient had nasal endoscopy with debridement of crusts, exudate and blood clots.  

Based on available medical literature, the American Academy of Otolaryngology - Head and Neck Surgery, which is the principal scientific organization for the specialty of Otolaryngology, concluded the following in their position statement of debridement of the Sinus Cavity after endoscopic sinus surgery (ESS).  The position statement states in part:

It is the position of the Academy that postoperative debridement aids healing and optimizes the ability to achieve open, functional sinus cavities.  This also facilitates optimal instillation of topical therapies and saline irrigations, long-term disease surveillance, and endoscopically-derived cultures.

Similar improvement in control of inflammation and secondary infection is obtained by debridement in other subtypes of chronic sinusitis patients; particularly in recurrent/persistent bacterial infections and/or fungal sinusitis.  Debridement may also be required in patients with chronic crusting in the setting of previous endoscopic tumor surgery and/or paranasal sinus radiation.

The frequency with which the above mentioned procedure should be performed is a clinical judgment best made by the surgeon and determined on a case-by-case basis, with the patient's clinical interests as the criteria of need.  Setting an arbitrary limit on the number of debridements does not account for variability between patients in the healing process or severity of disease and can significantly jeopardize the quality of care which patients receive and negatively affect the overall outcome of ESS.

This physician acted within the standard of care to complete debridement of the nasal and sinus cavities.  Therefore, the post-operative nasal endoscopy with debridement after nasal surgery (e.g., septoplasty, turbinectomy) was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe asthma exacerbation

Treatment: inpatient admission 

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

This patient is a female child with a family history of asthma. The patient had been sick with diarrhea for a few days which was decreasing in frequency. When the patient was noted to have cough, wheezing and shortness of breath on the night before admission, the patient was brought to the Emergency Room (ER) for evaluation. In the ER the patient was noted to be in mild distress with mild retractions. There was moderate wheezing audible upon auscultation of the lung. The patient was diagnosed with dehydration and was given a bolus of intravenous (IV) normal saline. In addition, the patient was treated with albuterol. The patient's chest x-ray was negative for pneumonia. The patient's testing for RSV and influenza were negative. When the patient's respiratory distress did not improve, the patient was administered IV magnesium in the ED. The decision was made to admit the patient with a diagnosis of status asthmaticus for ongoing treatment with albuterol every 3 hours.  

Based on the review of the literature, the patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. When there was ongoing respiratory distress with wheezing and increased work of breathing, it was appropriate and consistent with the standard of care to admit the patient to the hospital for ongoing treatment with albuterol every 3 hours. The patient's respiratory status did not improve with bronchodilator treatment in the ED. The patient's infectious workup was unremarkable. However, there was concern for dehydration with this patient's persistent respiratory symptoms despite ED treatment. The patient's clinical presentation prompted the need for intravenous magnesium sulfate administration. According to UpToDate, the use of intravenous magnesium sulfate is limited to patients with severe asthma exacerbations while in the ED or for those who require ICU care.

 In this case, the intensity of the treatment that this patient received in the ED was consistent with severe asthma exacerbation, which was this patient's admitting diagnosis. Consistent with literature, this patient's treatment plan included administering ongoing treatment with albuterol 3 hours. This treatment and close monitoring could not have been reliably provided at a setting less intensive then inpatient level of care. Thus, inpatient admission was medically necessary to treat this patient's medical condition. 

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

The carrier's denial of coverage for the inpatient admission should be reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Suicidal ideation with multiple

Treatment: continued inpatient mental health treatment

The insurer denied coverage for continued inpatient mental health treatment. The denial is modified. 

This patient is a male was admitted to this inpatient mental health in this hospital due to suicidal ideation with multiple plans including overdose and hanging, psychotic symptoms including auditory hallucinations, responding to internal stimuli, disorganized thinking, paranoid delusions, circumstantial thinking, depressed and irritable mood, poor insight and judgment, guardedness, uncooperativeness, non-compliance with medications, and he was using cannabis. He had multiple past psychiatric hospitalizations and was homeless. He had a diagnosis of Schizoaffective Disorder. He took Latuda and Depakote. He reportedly was discharged.

The insurer denied coverage for continued inpatient mental health treatment in this hospital. 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. Notes reported auditory hallucinations, responding to internal stimuli, poor ADL's, noncompliance, poverty of thought, irritable and depressed mood, and he was uncooperative. Other notes reported that he still had depression, irritable mood, and auditory hallucinations. This was a high risk patient with continued psychotic symptoms who had 2 suicidal plans on admission, multiple past psychiatric hospitalizations, and substance use, and he required continued psychiatric hospital treatment then. He needed a day of observation without psychotic and severe depressive symptoms or suicidal thoughts and then was considered appropriate for discharge after a specified time. Other notes reported that he denied suicidal or homicidal ideation, plan, or intent, auditory hallucinations and that he did not want rehab follow up and was going to be discharged to the to another facility. He was discharged.
Continued inpatient mental health treatment in this hospital from specified dates was medically necessary, but continued inpatient mental health treatment in this hospital from other dates specified was not medically necessary.  It appeared that the insurer acted reasonably and with sound medical judgment and in the best interests of the patient from the latter date range but not from the former date range.

Based on the above, the medical necessity for the 14 units of the inpatient mental health treatment code 0124 is substantiated in part.  The insurer's denial is modified as noted above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Premature ventricular contractions
	
Treatment: inpatient hospital admission

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

This patient is a man with a history of supraventricular tachycardia and gastroesophageal reflux disease. He presented to the emergency room with complaints of dizziness, shakiness, and shortness of breath. He had undergone a recent ablation procedure and had been seen in the emergency room. His symptoms were debilitating and he was unable to exert himself. At that time Flecainade dosage was decreased from 150 milligrams twice a day to 50 milligrams twice a day. On an electrocardiogram was done in the emergency and revealed sinus rhythm with frequent premature ventricular contractions. The patient was admitted with premature ventricular contractions. Cardiology services consulted over the case and they recommended stopping flecainide and performing a repeat ablation procedure. He underwent a supraventricular tachycardia ablation with no complications. After the procedure the patient was placed on bedrest for four hours and 81 milligrams of aspirin were given daily. The plan was to ambulate and not remain on bedrest. Premature ventricular contractions improved after the procedure. The care plan was implemented and the patient was discharged after a period of medical stability. 

Inpatient admission was not medically necessary. From his initial presentation, he was clinically and hemodynamically stable and did not require inpatient hospital admission. The patient underwent an uneventful electrophysiology study with ablation, with no complications, remained hemodynamically stable, was ambulatory, and was tolerating oral intake. There were no hemodynamic or clinical complications or concerns noted. Per MCG 23rd Edition Guideline for Electrophysiologic Study and Intra-cardiac Catheter Ablation, this procedure is an outpatient one, with allowance of one night in the hospital at observational status. 

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

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: Upheld

Cardiac/Circulatory Problems
Inpatient Hospital

Diagnosis: Syncope
Treatment: Inpatient Stay. The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male with history of human immunodeficiency virus (HIV) and ART (well controlled, undetectable viral load) who was brought into the emergency department (ED) by Emergency Medical Services (EMS) after he had an episode of passing out (syncope) after he got up from his table when he finished his meal. 

The inpatient hospital stay is not medically necessary. A safe prospective real time care plan could have been initiated at a lower level of care based on the available medical literature both in topics of syncope and pneumonia.
The patient had URTI (upper respiratory tract infection) symptoms ongoing before the episode of syncope. Syncope resulted in ED evaluation. Considering that the physical exam, EKG, telemonitor, and labs were all normal for evaluation of syncope, a lower level of care was medically appropriate in this situation (1). In addition, the findings on computed tomography (CT) raised consideration of infectious process including TB. His Pneumonia Severity Index (PSI) score/ curb 65 score was low which could have also been managed at a lower level of care as TB isolation was pursued at the time of initial evaluation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This male patient has a past medical history significant for hypertension, diabetes mellitus, hyperlipidemia, and eczema who presented to the Emergency Department (ED) with complaints of right ear pain and rash. The patient's vitals on ED presentation included: Temperature 97.5 F, Blood Pressure 153/87, and Pulse 63, Respiratory Rate 16, and Oxygen (O2) saturation 95% on Room Air. The patient's laboratory results included the following: white blood cell (WBC) count 7.8, hemoglobin (HGB) 16.0, hematocrit (HCT) 48, and creatinine 1.1. The patient was started empirically on intravenous (IV) fluids and antibiotics (i.e., vancomycin and clindamycin) for right ear cellulitis.  Dermatology was consulted over the case, and wound cultures were collected.  The patient remained afebrile, hemodynamically stable, and clinically improved.  The patient was discharged to continue outpatient management on oral antibiotics. 
 
According to documentation, the patient presented with a right ear rash/cellulitis.  Otherwise, the patient was afebrile, hemodynamically stable with unremarkable laboratory results including a normal white blood cell (WBC) count.  Documented "failure" of outpatient intervention by itself does not warrant automatic hospitalization.  The patient was treated as an outpatient with Bactrim then doxycycline.  Both outpatient antibiotics had anti-staphylococcal coverage. However, they were less effective compared to clindamycin against streptococcal skin infections.  The patient did not have any evidence for a disseminated infection and no surgical intervention was required.  Based on these clinical findings, the patient could have been safely treated and monitored at an observation level of care. Literature review does not support that full hospital admission was medically necessary for this patient.

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

The carrier's denial of coverage for the full inpatient hospital admission should be upheld.  The medical necessity is not substantiated.