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

Diagnosis:  Dizziness
 
Treatment:  Inpatient admission, diagnostic testing, monitoring

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

This is a male with a history of nephrolithiasis and inguinal hernia repair.  The patient was brought to the emergency room (ER) after he was found outside vomiting.  The patient had a 1-day history of dizziness and vomiting.  Ambulance documentation indicated the patient was initially "in and out of consciousness."  An electrocardiogram (EKG) revealed normal sinus rhythm.  The patient's vital signs upon presentation were blood pressure of 116/65, heart rate 82, respiratory rate of 18, and temperature 97.4 F.  He was lethargic but could follow commands.  He had weakness in both legs.  The remainder of the physical and neurological examination was normal.  The patient's white blood cell count was 15.6 K; an alcohol level was less than 10; a urine toxicology was positive for marijuana.  A CT scan of the head was normal.  The patient was treated with Benadryl, dexamethasone, meclizine, and antiemetics.  He had continued dizziness and was admitted for vertigo, as he was deemed at high risk for cerebrovascular accident (CVA).  He underwent an MRI of the head, which was normal.  The patient was stabilized and was discharged.

Milliman Care Guidelines recommends the goal length of stay for patients with dizziness is ambulatory or one day.  Inpatient admission is for patients with dizziness when they have signs or symptoms that are severe and persistent (e.g., inability to ambulate after observation care treatment), for vomiting that is severe or persistent, for cardiac arrhythmias of immediate concern, when there is a severe (new) neurologic finding requiring inpatient care, or where the patient has other conditions, treatment or monitoring requiring inpatient admission.  The patient did not have new or severe neurologic findings.  The records submitted failed to support the patient could not have been placed at an observation level of care, rather than admitting the patient acutely. 

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

This is a patient with a history of hypertension, noncompaction cardiomyopathy, mild left ventricular systolic dysfunction, ventricular tachycardia and paroxysmal atrial fibrillation. She has an implantable cardioverter defibrillator. She underwent elective catheter ablation for her atrial fibrillation. The procedure was uncomplicated. She was discharged home the following day. The health plan's determination is upheld.
Given the complexity of the procedure, with transseptal punctures, catheter manipulation and ablation within the left atrium, full dose anticoagulation, and the proximity of the ablation lines to the esophagus, the complication rate is higher with atrial fibrillation ablation than with catheter ablations for other supraventricular arrhythmias. Despite at least two reports demonstrating the safety of same day discharge after this procedure, most electrophysiologists admit the patients for overnight observation post-procedure. This patient's procedure was uncomplicated, and she was hemodynamically stable.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Monocular esotropia strabismus of the right eye
Treatment: Elective Outpatient-Outpatient Procedure
The proposed treatment, strabismus repair, is medically necessary per standard of care.

It has been estimated that up to four percent (4%) of the adult population has strabismus, and strabismus surgery is commonly performed on Medicare-aged patients. Childhood strabismus may persist into or recur in adult life. Adults may also develop new-onset strabismus as a result of such varied conditions as microvascular cranial neuropathies, trauma, thyroid-related ophthalmopathy, cerebrovascular disease, or as a consequence of previous ocular or orbital surgery.

According to the Joint Statement of the American Association for Pediatric Ophthalmology and Strabismus and the American Academy of Ophthalmology, adult strabismus surgery seeks to restore/reconstruct normal ocular alignment. Indications for surgical intervention in adult strabismus include diplopia, visual confusion, restoration of binocular vision, intolerance of prism glasses or patch, restoration of visual field, elimination or improvement of abnormal head posture, or psychosocial function/vocational status. If eyes are not aligned, there is loss of binocular vision or fusion that allows for appreciation of depth in three-dimensional space. Binocular vision can be restored by strabismus surgery. Even adults who had childhood strabismus can regain fusion following strabismus surgery. Numerous studies have focused on the postoperative binocularity of adults undergoing strabismus surgery. Of the 324 consecutive adult patients studied in Kushner's series, 70% regained binocularity, as measured by the Bagolini lens test. When all of the series that reported binocular status before and after surgery were combined, 979 of 1488 (66%) patients demonstrated restoration of sensory binocular fusion after strabismus surgery. A variety of methods, including Bagolini lenses and Titmus, Lang, and Worth binocular tests, were used to measure binocular status. Regained binocularity rates of 30% to 100% were described in individual reports. Sensory fusion after strabismus correction is not limited to patients with strabismus acquired in adulthood. 

In this case, the patient has residual esotropia of the right eye.  Strabismus surgery is proposed to repair a large angle residual esotropia from childhood with the goal of restoring ocular alignment, potentially restoring some binocular vision and improving psychosocial function. Therefore, medical necessity for strabismus surgery is established per standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Drug use, agitation, hallucinations
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

This patient with a history of drug overdose was admitted with benzodiazepine withdrawal.  Benzodiazepine withdrawal can be safely managed as an outpatient unless: other major medical or psychiatric problems co-exist; the patient takes a high dose (greater than (>) 50mg diazepam equivalent per day); or there is use of central nervous system (CNS) depressants.  Evaluation showed the patient had tachycardia but was hemodynamically stable.  Labs were unremarkable and EKG was normal.  The dosage of benzodiazepines is unknown as this was illicit use and the patient did not provide a specific quantity/dosage consumed. CNS depressants were not associated.  The patient did not have a major medical or psychiatric problem that required an acute inpatient level of care.  During the hospital stay, the patient remained clinically stable with no signs of withdrawal that require an acute inpatient level of care.  The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of hypertension, Graves disease and depression. The patient presented to the emergency department complaining of three days of vomiting, diarrhea and throat pain. The patient reported blood streaked emesis. The blood pressure was 133/92 mmHg with a heart rate of 106 beats/minute. The respiratory rate was 18/minute with a room air oxygen saturation of 99%. The patient was afebrile. The patient was admitted to the hospital. The inpatient stay is under review. 

The health plan's determination is overturned. The inpatient stay was medically necessary for this patient. This patient presented with atypical symptoms that, given his elevated serum troponin level, were thought to possibly represent acute coronary syndrome (ACS). Given the significant risk for heart failure and potentially lethal arrhythmias in patients with ACS, the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes recommends inpatient admission for patients in whom ACS is suspected and who have elevated cardiac biomarkers. The patient's troponin elevation was ultimately attributed to demand ischemia due to his systemic inflammatory response syndrome (SIRS). While this is not indicative of ACS, elevated troponin levels are common in patients with SIRS and sepsis are are an indicator of poor prognosis. Nearly 80% of patients with SIRS or sepsis and elevated troponin levels develop left ventricular systolic dysfunction; all cause mortality is increased as well. Thus, even in the absence of ACS, the inpatient admission for this high risk patient was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission upheld. 

This is a young male patient who presented to the emergency department (ED) after having a witnessed seizure at school. It was reported that the patient was sitting down and began to experience seizure activity. Upon arrival to the ED, the patient was alert and oriented x 4; it was unknown whether the patient had hit his head upon falling.  Pediatric cardiology and neurology were consulted. A magnetic resonance imaging (MRI) was performed, which was normal, and an electroencephalogram was negative. The patient was observed, stabilized, and discharged home with instructions to follow up with the pediatric neurologist.

The MCG indicates that the goal length of stay for a pediatric patient with a seizure is ambulatory or 1 day. Admission would be appropriate for a patient who had status epilepticus or repetitive seizures not controlled with emergent treatment, hemodynamic instability, brain disorder, cardiac arrhythmia of immediate concern, a new focal neurologic deficit, or altered mental status that is severe or persistent. The records submitted for review indicated that the patient was hemodynamically stable. He was not noted to have a repetitive seizure. The diagnostic studies that were performed could have been performed on an outpatient basis.  

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: Chest Pain

Treatment: Hospital Admission

The insurer denied the Hospital Admission. The denial was upheld.    
This patient presented to the Emergency Room with complaints of chest pain. He has a past medical history of diabetes mellitus, hypertension, high cholesterol, tobacco use in remission, and liver disease. A computerized tomography of his chest was performed which was negative for aortic dissection, aneurysm, or intramural hematoma. The patient had a cardiac catheterization which showed non-obstructive coronary artery disease. 
He had transesophageal echocardiogram which revealed an ejection fraction of 55%. He was ruled out for a myocardial infarction. He left the hospital against medical advice.

In the absence of elevated cardiac biomarkers and a diagnostic electrocardiogram, 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 was not met. Although the patient had new onset symptoms, the medical criteria were not met for any other additional extenuating circumstances. There were no other high risk comorbidities. 

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

Diagnosis: Symptomatic Anemia
 
Treatment: Inpatient Admission

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

This is a patient who presented to the Emergency Department with complaints of lightheaded sensation, weakness, and abdominal pain at her umbilical site with nausea. It was reported that six months earlier the patient required a blood transfusion due to anemia. The patient's vital signs were within normal limits while in the emergency department. Laboratory testing revealed the patient's hemoglobin was 5.4. She was transfused two units of packed red blood cells. It was reported that the patient was non-compliant with her iron administration. It was recommended that she follow up with a hematologist for possible intravenous iron therapy. The patient was hemodynamically stable and discharged home with instructions to follow up as an outpatient. 

According to the referenced guidelines, admission is indicated for a patient with hemodynamic instability such as a vital sign abnormality that is not readily corrected by appropriate treatment within 24 hours.  Additionally, a patient may be appropriate for admission when there is evidence of active hemolysis, altered mental status, cardiac arrhythmias of immediate concern, recurrent syncope, acute renal failure, high risk low platelet count, or there is an urgent inpatient surgery needed.  Within the documentation the above was not noted.  The documentation did detail the patient was in need of a transfusion.  The documentation detailed she also complained of mild abdominal pain. However, it was noted she also had a hernia present.  There are multiple laboratory and diagnostic studies that did not reveal any acute surgical needs.  The patient did have improvement in her hemoglobin and hematocrit after transfusion.  There was no evidence the patient had any significant hemodynamic instability. 

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: Influenza
Treatment: Inpatient admission
The proposed treatment of inpatient admission is not deemed medically necessary. 

This was a female who presented to the ER for further evaluation/management of dyspnea, chills and sore throat. Intake vitals were notable for febrile temperature of 100.7; vitals otherwise were hemodynamically stable with no evidence of profound hypotension, tachycardia or respiratory distress. Examination was non-focal with no significant abnormalities noted including no evidence of severe cardiopulmonary abnormalities. Laboratory testing was notable for positive rapid Influenza testing but otherwise was without evidence of severe abnormalities or findings consistent with end organ failure. Chest x-ray was negative for focal consolidation. The patient was admitted to the inpatient medical service in stable condition where she received treatment with intravenous (IV) Lasix, Tamiflu and broad spectrum IV antibiotics. She improved with the prescribed therapies and was subsequently discharged in stable condition. There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oligohydramnios

Treatment: Inpatient admission 

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

This patient is a female who was referred to a hospital because of a fetal heart rate of 155 beats per minute and a decreased amniotic fluid index (AFI = 4.9). She was 34.5 weeks pregnant. A sonogram was performed which revealed poor growth with an estimated fetal weight (EFW) in the 10%.  The patient's vital signs were within normal limits. She denied complaints of contractions, bleeding and/or leaking. The patient was hydrated and the fetal heart rate was reactive. Preterm premature rupture of membranes (PPROM) was ruled out. Pregnancy induced hypertension was ruled out. The patient was admitted. The resident's progress note stated that the patient is being admitted for oligohydramnios. The attending physician note stated that the patient is being admitted for intrauterine growth restriction (IUGR). A progress note indicated that the patient and fetus were doing well. A progress note reported that the patient was doing well. The AFI had improved. The plan was to keep the patent in the hospital over the weekend. The ultrasound performed found that the AFI and the biophysical profile (BPP) were normal. The patient was to be discharged home.

It is unclear why this patient was admitted. There was no elevation in her blood pressure. Her membranes were not ruptured. The fetal heart rate was reactive and there were no contractions.

MCG list the following clinical indications for antepartum admission:

1)	Condition requiring premature delivery
2)	Delivery
3)	Fetal distress or demise
4)	Preterm labor and positive fetal fibronectin [fFN]
5)	Significant maternal disease, infection or comorbidity as cause
6)	Significant vaginal bleeding or any vaginal bleeding with known placenta previa, vasa previa or placenta accreta
7)	Continued fetal monitoring
8)	Tocolytic therapy that requires inpatient care
9)	Complications of tocolytic treatment

This patient did not have any of the above. The only reason the patient was admitted was for prolonged fetal heart monitoring. Monitoring does not require admission. The patient could have been monitored for a few hours and, if as stated the fetal heart rate was reassuring, she could have been sent home to be followed up as an outpatient. According to MCG, fetal monitoring is not an indication for admission; however, fetal compromise is. Based on all the data submitted, there was no evidence of fetal compromise.

Based on the above, the patient could have been observed and once the provider ascertained that both mother and fetus were stable, the patient could have been sent home to be followed closely as an outpatient.

The inpatient hospital admission was not medically necessary. The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

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:  Bright red blood per rectum
Issue under review:  Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient presented with a one-day history of bleeding per rectum with blood mixed in the stools, and blood in the tissue paper.  She has a history of constipation due to iron supplements.  She denied any h/o abdominal pain, nausea, vomiting, fever or chills.  She was hemodynamically stable and afebrile on admission.  Her CBC revealed normal Hb/HCT.  She had mild hyperkalemia, which was corrected with Kayexalate.  She was started on IV fluids and IV PPI (proton pump inhibitor) drip.  Over next 24 hours, she remained stable with no recurrence of bleeding per rectum, and her Hb/HCT remained stable.  Given this clinical scenario, she could have been appropriately managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient has hypertension, hyperlipidemia, and paroxysmal atrial fibrillation. A lipid panel showed a total cholesterol of 302, low density lipoprotein (LDL) of 216, high density lipoprotein (HDL) of 66 and triglycerides of 114. Apolipoprotein B was 167, lipoprotein (a) was 540, and lipoprotein particles small LDL p was 312. Under review is the medical necessity of the lipoprotein testing.

The health plan's determination is upheld. The requested lipoprotein measurement is not medically necessary. This patient has elevated total cholesterol and elevated LDL. LDL is the main target of lipid lowering therapy for reduction in cardiovascular events. The additional measurements of Lp(a), apolipoprotein B, and lipoprotein particles is not necessary, as it would not alter recommendation for treatment. Current American College of Cardiology (ACC) guidelines for lipid lowering consider LDL the major target of therapy, with statins the primary medication used for treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major Depressive Disorders
 
Treatment: Continued Inpatient Hospital Admission

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

This is a middle age female who was admitted to an inpatient psychiatric hospital due to depressive symptoms that include depressed mood, suicidal ideation of not wanting to live but had no plan or intent. She also expressed feelings of worthlessness and isolation.  She had past history of Major Depression Disorder, seizures, cerebral palsy, and overactive bladder. She reports no previous psychiatric hospitalizations or treatments. The patient was treated with Lexapro, Abilify, Trazodone, Haldol, and Ativan. She was isolative but did participate in art group. While hospitalized, she remained depressed and suicidal. She was discharged after a period of stability.

Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders report 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 ideation with depressed mood and feelings of worthlessness and was approved for hospital treatment. There were no reports of suicidal plan, intent, or behavior, self-injurious behavior, inability to adequately care for basic needs, psychotic or manic symptoms, aggressive, severely agitated, or threatening behavior, acute medical issues, or substance use issues as she denied substance use. She had no past suicide attempts, and no past psychiatric hospitalizations. She reportedly was living in a shelter but the chart notes that there was not specific evidence that she was an imminent danger to self or others or unable to adequately care for her basic needs. 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.

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