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

This is a patient with anxiety and depression admitted for a video electroencephalogram (EEG) for 24 hours in the setting of two episodes of shaking seizure like activity concerning for pseudoseizures that occurred at school on the day of admission. In the emergency room, the patient was afebrile, had shaking of the upper and lower extremity and eye fluttering which stopped with Ativan 2 milligrams (mg). During the shaking episode, the patient was responsive and following commands by shaking her head yes and without a verbal response to questions. There was no loss of consciousness, confusion or postictal period. The patient's neurological exam was entirely normal with no focal deficits in speech, gross or fine motor function or gait. The patient's neurologist was contacted and stated that the patient had an outpatient work up with a spot electroencephalogram (EEG) and magnetic resonance imaging (MRI) in the past which had all been normal. The neurologist had diagnosed her with pseudoseizures. Neurology at the admitting hospital was consulted and the patient was admitted for 24 hour video EEG monitoring.  She had no episodes of seizure like activity. She did not require additional medications. She did exhibit anxiety. EEG monitoring was completely and officially reported negative for seizure activity. The patient reported that she was seeing a counselor and psychiatrist. The health plan's determination is upheld. She is known to have pseudoseizures and the ER doctor felt the current episode was also a pseudoseizure. The patient's neurologist provided information that the patient had negative MRIs and EEGs in the past. At the time she was admitted to the hospital, there was no mention of altered mental status, she did not have any true neurological deficits, she was not toxic appearing, there was no mention of meningeal signs, no intractable vomiting or severe headache. While admitted, she did not require any complex or highly technical skilled care. She was observed, had a video EEG and had no recurrence of symptoms.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dyspnea (secondary to bronchiolitis)
Treatment:  Inpatient admission

The inpatient admission was not medically necessary.

The patient is female infant born full term that was referred to the ED by the pediatrician because of one-day history of subjective fever (axillary temperature 100) and difficulty breathing.  She was having difficulty feeding because of nasal congestion. 

Vital signs included temperature 37.7, heart rate 186, respiratory rate 48, and 98% saturation in room air.  Examination was significant for no distress, well-hydrated appearance, vigorous strong cry, moist mucous membranes, nasal congestion, mild expiratory wheezing with mild tachypnea (50s-low 60s), no murmur, and non-focal neurologic exam.  Lab studies and viral panel were obtained; she was given a trial Duoneb treatment, and she was given a fluid bolus. 

The patient was admitted for management of bronchiolitis and decreased intake due to young age and nasal congestion.  Laboratory testing was significant for mild leukocytosis (white blood cell [WBC] count 17.83K with left shift of 3% bands, 3% metamyelocytes, 2% myelocytes), negative C-reactive protein (CRP), negative viral panel, and elevated potassium (6.3) on basic metabolic panel (BMP).  Because of the slight increase in potassium, an electrocardiogram was performed upon admission that was normal. 

Chest x-ray performed the next day in the early morning revealed right upper lung patchy focal consolidation worrisome for airspace disease.  Admission orders included supportive care with supplemental oxygen as needed to maintain saturations greater than 90%, maintenance intravenous (IV) fluids, ad lib feedings unless tachypneic, urine studies if fever spike, and zinc oxide for a diaper rash.  The patient remained afebrile.  IV fluids were discontinued, and she was allowed to feed, which she did without difficulty.  She had no respiratory difficulty or wheezing on exam.  Repeat potassium was 5.4.  She was deemed stable for discharge to follow-up with her pediatrician in one to two days. 

This female infant presented to the ED with signs and symptoms consistent with mild bronchiolitis.  She had low-grade fever, nasal congestion, some increased work of breathing with tachypnea, and decreased feeding.  She had no vomiting/diarrhea, oxygen requirement, signs of sepsis or significant dehydration (she was still making normal number of wet diapers and had moist mucous membranes), or signs of impending respiratory failure.  She was overall hemodynamically stable.  She did not require acute inpatient admission, and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post tonsillectomy, adenoidectomy and bilateral tympanostomy tube placement 

Treatment: Inpatient admission

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

This patient is child who presented to the Emergency Department.  The patient presented status post tonsillectomy, adenoidectomy and bilateral tympanostomy tube placement.  The patient had decreased oral intake secondary to pain, as well as a fever for one day.  The patient also had postoperative bleeding for one day.  Upon arrival to the Emergency Department, the patient had a low grade fever. The patient was tachycardic at 117 beats per minute (bpm) and was tachypneic up to 27 breaths/minute.  The patient had a slightly elevated blood pressure of 123/79 mmHg.  She had granulation tissue on the tonsils with white exudates and no sign of active bleeding.  The patient had dry lips and good capillary refill.  The patient received one normal saline bolus, one dose of ketorolac and was started on intravenous maintenance fluids, as well as ranitidine.  One dose of Decadron was given.  The Ear, Nose, and Throat (ENT) physician was consulted, and the patient was admitted to the Pediatric inpatient unit for intravenous rehydration and re-evaluation by the ENT physician, as per their recommendations.  The patient was subsequently cleared for discharge and the patient's pain was well controlled.  The patient was able to tolerate clear fluids and was deemed appropriate for discharge.
MCG indicates that admission for pediatric dehydration may be appropriate for a patient with dehydration that was severe or persistent, when oral rehydration therapy was not tolerated or was insufficient to adequately control dehydration, and when the appropriate intravenous treatment does not readily correct dehydration after 12-24 hours of treatment.  The records submitted for review failed to support that the patient had been treated for 12-24 hours with rehydration prior to admission.  The patient had a low grade fever.  The patient was not actively bleeding at the time of admission.  The patient could have been observed for up to 23 hours.  The records failed to support that the observation level of care would not have been appropriate.  As such, the healthcare plan acted reasonably, and with sound medical judgment, and in the best interest of the patient.  The acute inpatient admission is not considered medically necessary for this patient.

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

This is a patient who was brought to the emergency department (ED)  via Emergency Medical Services (EMS) from the pediatrician's office because of black stools and coffee ground emesis. With the current presentation, he reported periumbilical pain and one normal stool followed by an episode of black stools and coffee ground emesis. When EMS arrive at the office, he was found to be normotensive. His hemoglobin was low at 7.9. He was treated with Zofran, a normal saline bolus, and pantoprazole. A gastroenterology (GI) consult was requested, with the possible need for endoscopic evaluation.  Physical examination following admission was significant for tenderness in the epigastric region.  The health plan's determination is overturned.
Gastrointestinal bleeding, both upper and lower, is potentially a life-threatening situation.  For patients with a convincing history but not active bleeding, GI protection with proton pump inhibitor medications is necessary, and after any necessary hemodynamic stabilization, endoscopy is required identify the etiology of the bleeding. In this patient's case, he presented with evidence of upper GI bleeding (coffee ground emesis, black tarry stools) and hemoglobin 7.9 indicative of potentially longstanding issues. He was referred from the pediatrician's office because of hypotension and tachycardia. Following fluid resuscitation and transfusion, he was taken to the OR for endoscopic evaluation, and was noted to have distal gastritis, duodenitis, and superficial ulcerations. Biopsies were obtained to evaluate for Helicobacter (H.) pylori infection. He was discharged once he was able to tolerate an appropriate diet and had stable hemoglobin following transfusion.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Small Gestational Age
Treatment: Norditropin FlexPro 10mh/1.5ml pen injector
The insurer denied Norditropin FlexPro 10mh/1.5ml pen injector. The denial was upheld. 
This is a young male patient who was diagnosed with small for gestational age (SGA). 
The patient is a twin that was born at 24 weeks gestational age with a birth weight of 1 pound 3 ounces. His history includes asthma, eczema, hypothyroidism, developmental delays, short stature and premature adrenarche. He was followed by a pediatric endocrinologist. He had diagnostic testing that included; bone age study, a height and weight growth evaluation. It was noted that the patient had two borderline abnormal fecal calprotectin studies in the setting of not gaining weight. A gastroenterology consult was requested. The patient's family was not previously interested in growth hormone, but is now requesting it.  

Growth hormone for the treatment of children who are small for gestational age (SGA) and who fail to exhibit catch-up growth is standard of care.  This indication has approval from the FDA(1) support from consensus guidelines (2-4) and randomized controlled trial evidence to support its use.(5-9) The most recent and most relevant consensus guidelines are those of the combined meeting of the International Societies of Pediatric Endocrinology and the Growth Hormone Research Society.(2) Here it is recommended that if a patient fails to exhibit catch-up growth by either two or four years, that GH therapy be initiated.  At age 4 years this is defined as <2SD. The diagnosis of Small for Gestational Age (SGA) is made at birth.  The diagnosis of SGA with failure to catch up is made after a growth point at age 2.  This diagnosis can be made at any time after age 2 assuming that the patient has not had catch up growth to above -2SD.  For example if a patient is found at age 8 and is still has still not caught up, then this patient would qualify for the SGA indication. 

This patient was not SGA at birth. The cutoff for SGA at 24 weeks is 500g. The patient was 539g. The patient was therefore not SGA at birth.  Furthermore the patient has caught up to a height taller than -2SD. The request is not consistent with generally accepted standards of medical practice. 

The carrier's denial of coverage for Norditropin FlexPro 10mh/1.5ml pen injector is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Lupus
Treatment:  Inpatient admission

The inpatient admission was not medically necessary.

This patient with SLE presented with joint pains and two episodes of loose stool with BRBPR.  She was afebrile and her vital signs were stable.  She did not have abdominal pain, and rectal exam did not reveal active bleeding.  Her hemoglobin and renal function were normal, and inflammatory markers were normal.  She had no further episodes of bright red blood per rectum (BRBPR) in the hospital and tolerated an oral diet.  She was treated with intravenous pain medication for joint pains, and prednisone 20 mg was given prior to discharge with outpatient follow up.  Her presentation and level of care could have been safely and reasonably accomplished in the outpatient hospital setting, and did not require an inpatient hospital admission.  Thus, the proposed inpatient hospitalization for this patient was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department (ED) with urinary frequency, subjective fever at home, malaise and pleuritic chest pain radiating to the shoulder. The patient underwent coronary artery bypass graft (CABG) recently.  The surgery was complicated by a pleural effusion, and patient underwent PIG Tail catheter placement for drainage of the pleural effusion. In the ED, initially patient was afebrile, and  vitals were normal. However, temperature went up to 102.4 and labs revealed a white blood cell count (WBC) 13.05. Troponin was normal. A chest x-ray (CXR) was normal. Urinalysis revealed bacteria and protein. Patient received Vancomycin and Tylenol, was started on intravenous fluids, An echocardiogram was negative for pericardial effusion. The patient was discharged home with antibiotics for a urinary tract infection (UTI). The requested health service/treatment of Inpatient Stay was not medically necessary for this patient. The HP determination is upheld in whole. There were no indications for an inpatient admission based on his UTI. The patient presented with pleuritic chest pain, which was not cardiac. His pleuritic chest pain did not require inpatient admission.The management of this patient was appropriate, but could have been provided under a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain
Treatment:  Inpatient admission
Inpatient level of care was not medically necessary.

This patient had atypical chest pain with no objective evidence of ischemia.  Routine rule out (r/o) acute coronary syndrome (ACS) protocol was followed.  Neither the testing nor the treatment required an inpatient level of care. 

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care.  This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and it is highlighted in the orders for care. 

In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome.  Exam and cardiac findings were normal.  Biomarkers and EKG showed no evidence of acute ischemia.  CXR was normal.  CT calcifications are a marker for a higher probability of CAD but not ischemia itself.

The physicians' treatment did not include medical therapy for ACS, such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG).  Cardiac catheterization was performed and was uncomplicated, and there was no evidence of significant obstructive disease.  Recovery was unremarkable.

The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care.  The only post-catheterization cardiac care provided was telemetry, frequently performed in a lower level of care.  The patient was admitted for monitoring, and subsequent tests and therapy did not require an inpatient level of care.  There was no complex care that required inpatient care.  This patient had no evidence of significant CAD.  Radial catheterization was developed with one of its advantages being the safety in early ambulation and discharge.  The overnight stay for observation and telemetry does not change that determination.  While possible, bleeding post radial artery catheterization is rarely seen, nor does it require extended monitoring.  In fact, all tests showed absence of ischemia.  While there is always a potential for an adverse event (and in this case a very low probability), one did not happen, and no actual treatment was added.

Milliman criteria requirements were not fulfilled, as there was never any evidence of ACS present.  Cardiac monitoring for atypical chest pain is appropriate at a lower level of care.  The cardiac catheterization performed was not emergent or high risk, as no significant obstructive disease was seen, and no intervention was required.  All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care.  Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post staged right lower extremity revascularization
Treatment: Inpatient stay

Summary:
This patient presented for an elective staged lower extremity revascularization procedure.  The procedure was a success, and no complications were noted both intraoperatively and following the procedure.  The patient was observed overnight and clinically stable for discharge the following day. Several investigators have demonstrated that same day/early discharge following endovascular revascularization without hospital admission is feasible and safe. In conclusion, this patient was not noted to have any complications during or following her procedure and it was appropriate to manage at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Persistent depressive disorder, unspecified anxiety disorder, and alcohol and cannabis use disorder
Treatment: Mental health residential admission 

Summary:
Throughout the patient's residential/wilderness stay, there was no documented evidence of suicidal ideation, psychosis, cognitive problems, impairment in activities of daily living or any other condition requiring 24-hour daily observation and treatment. She showed no signs of alcohol or drug dependence and had no withdrawal symptoms or medical comorbidities. She was highly defended and was resistant to treatment. 
Such problems are best addressed on a long-term basis, in ongoing therapy with a competent psychotherapist. The patient could have been safely and effectively treated on a lower level of care, such as outpatient or intensive outpatient treatment.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Sickle cell crisis and pneumonia
Treatment: Inpatient admission
Admission was medically necessary, in part. 

The patient presented with fever, pain and tachycardia.  Chest x-ray and CT were concerning for possible pneumonia.  Given his chest pain and shortness of breath, acute chest syndrome was also suspected.  Given those considerations and his continued difficulty with pain in the emergency department despite treatment with pain medication, the patient could not be managed at a lower level of care.  He had tachycardia but what was described as a stable blood pressure for him.  As of the third day, the patient could be managed at a lower level of care. He had no other significant issues, and notably no significant organ compromise or signs/symptoms suggestive of severe sepsis.  He did not have respiratory failure. He had no evidence of infection at that time and no recurrent fever or other acute medical issue active as of that time.  While it is noted that he had low-grade fevers with positive blood cultures following that, as of the third day he could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic short stature
 
Treatment: Nutropin

The insurer denied the growth hormone therapy. The denial was reversed.

This is a female child diagnosed with idiopathic short stature (ISS). Her growth hormone (GH) stimulation test peaked at two different ages. Her bone age was that of a child less than her chronological age (CA). Her IGF1 was 83 (76-424) and IGFBP3 was 3.1 (1.6-6.5). Her father's height is 162.56 cm and mother's height is 162.56 cm and so mid parental height is 156.06 cm (-2.88 SDS). Her height velocity is reported to be 3.5 cm/yr. Her puberty stage was at  tanner 1. 

Classic GH deficiency diagnosis is based on auxological, biochemical and sometimes radiological findings. The auxological criteria are 1) severe short stature, defined as a height more than 3 sd below the mean; 2) height more than 1.5 sd below the midparental height; 3) height more than 2 sd below the mean and a height velocity over 1 yr more than 1 sd below the mean for chronological age, or a decrease in height sd of more than 0.5 over 1 yr in children over 2 yr of age; 4) in the absence of short stature, a height velocity more than 2 sd below the mean over 1 yr or more than 1.5 sd sustained over 2 yr. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10ng/ml. The patient did not meet biochemical criteria. Growth hormone stimulation testing peaked at greater than 10. 

Growth hormone in the treatment of ISS is supported by randomized controlled trials and consensus guidelines. (4-9) FDA approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means." The patient has a pretreatment height less than or equal to -2.25 SD. The patient's height velocity of 4 cm per year is far below the normal range at -2.2 SD and would not allow her to reach a normal adult height. The patient met ISS criteria. The request is consistent with generally accepted standards of practice and is therefore medically necessary.

Based on the above, the medical necessity for Nutropin is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis; Foot ulcer
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient meets the initial criteria for IV treatment and admission for cellulitis/abscess given by the Infectious Diseases Society of America (1), as he had systemic signs of infection (elevated WBC count). Thus, this admission was warranted, supported by IDSA guidelines. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death. A lower level of care such as observation would not have been adequate for this patient's presentation and course.