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

Diagnosis: Unspecified chest pain

Treatment: Inpatient hospital admission

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

This patient is a male with a history of pulmonary embolism. The patient presented to the Emergency Department (ED) with complaints of chest pain radiating to the left arm for the past couple of weeks. The patient's vital signs were stable. The patient's troponin was negative. The patient's chest x-ray came back within normal limits, and the patient's electrocardiogram (EKG) revealed a normal sinus rhythm with T wave inversions. The patient was given 325 milligrams of oral aspirin. The patient was admitted to the Telemetry unit for unspecified chest pain. The patient's echocardiogram revealed severe left ventricular hypertrophy consistent with obstructive cardiomyopathy. The patient's coronary computed tomography angiography (CTA) revealed a calcium score of 0 and normal coronaries; there was left ventricular hypertrophy with possible aneurysm of the true apex. The patient's pulmonary computed tomography (CT) scan revealed no pulmonary embolism. The patient's cardiac magnetic resonance imaging was negative. The patient's cardiac enzymes remained negative during the hospitalization. The patient was discharged in stable condition.

Based on the review of the medical records provided, the patient presented with chest pain.  The patient's initial evaluation in the Emergency Department was unremarkable, including a non-diagnostic EKG and negative cardiac biomarkers. Inpatient admission was not medically necessary for this patient. Based on the review of the clinical guidelines for inpatient admission, this patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted, however inpatient admission criteria were not met. The patient did not have hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions that warranted acute inpatient level of care. Thus, inpatient admission was not medically necessary to treat this patient's medical condition.
The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Ear and facial pain; diabetes
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.
The insurer denied the inpatient admission.  The denial is upheld.

The patient is a female with type II diabetes, hypertension asthma, and depression. She who presented with ear and facial pain. 

The patient's BP (blood pressure) was 134/74. Her HR (heart rate) was 91, and T (temperature) 98.4. Her Glucose was 630 mg/dL, bicarb 20, anion gap 18, positive urine ketones, A1C (glycated hemoglobin) 14.1%. She was treated with insulin infusion and intravenous fluids. She was on cefpodoxime temporarily. She was transitioned to subcutaneous insulin. She was diagnosed with eustachian tube dysfunction. She was discharged.   

This patient presented with hyperglycemia and dehydration. She was hemodynamically stable. She did not have a bicarbonate level of less than 18 or significantly reduced pH level to document acidosis to support a diagnosis of diabetic ketoacidosis. She did not have altered mental status to support a diagnosis of hyperglycemic hyperosmolar syndrome. She had ear pain that was diagnosed as Eustachian tube dysfunction that did not require inpatient management. Therefore, no, the proposed inpatient stay was not medically necessary. 

The documentation does not support that this patient required an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The Inpatient admission was not medically necessary.

The patient is a male that presented to the hospital with chest pain.  He noted excessive alcohol intake prior to presentation.  His past history was significant for substance abuse and hypertension.  

Upon arrival, the patient's physical examination revealed stable vital signs and normal heart and lung examination. ECG (electrocardiogram) revealed no significant abnormality.  Serum cardiac enzymes were not elevated. CT angiogram revealed no evidence of pulmonary embolism or aortic dissection. The patient was admitted to the hospital and released the following day. 

This patient presented with chest pain that was of new onset radiating to his back.  No abnormalities or findings consistent with an acute coronary syndrome were noted.  Based on history and presentation alone, this patient had a low short-term risk of death and nonfatal cardiac ischemia.  He underwent exercise stress testing, which revealed no evidence of ischemia.  These findings are consistent with a low one-year mortality and a low probability of significant coronary artery disease.

Utilizing the HEART (History, EKG, Age, Risk factors, initial Troponin) score, he is considered low risk. Utilizing the TIMI (thrombolysis in myocardial infarction) risk score, he also had a low risk of developing major adverse cardiac events in the subsequent 30 days. 

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al.  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. Ultimately this patient underwent myocardial perfusion imaging that revealed no evidence of ischemia- confirming the aforementioned low risk stratification.  In conclusion, the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult male. He has a past medical history significant for sciatica. He presented to the ER for complaints of new onset chest pain, non-exertional, non-radiating, associated with diaphoresis after eating spicy food. He had no syncope. 

The patient's cardiac enzymes were negative. ECG (electrocardiogram) revealed sinus rhythm with 2:1 AV (atrioventricular) block with PVCs (premature ventricular contractions). His blood pressure was elevated. The patient was admitted to telemetry. 

The patient was seen in consultation by cardiology, and a treadmill stress test was recommended. The stress test revealed no evidence of ischemia, and a normal heart rate response with normal AV conduction. Lifestyle changes, smoking cessation and diet were recommended. The patient was discharged home with a plan for outpatient follow-up. 

This patient presented for evaluation of atypical chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. The ECG revealed transient 2:1 AV block, with no evidence of hypotension, bradycardia, syncope. Ischemia was ruled out by stress testing, and normal chronotropic response was documented with exercise. There were no plans for pacemaker placement, IV pressor support or EP (electrophysiology) study. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission. The care that was required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient is an adult male who presented to the ED complaining of chest pain, nausea vomiting, shortness of breath and palpitations.  Upon arrival in the ED his pulse was noted to have a narrow complex tachycardia at a rate of 192 beats per minute (bpm).  Pulse was subsequently noted to slow down to 110 bpm and was irregular; blood pressure was 85/58 mmHg.  Electrocardiogram revealed atrial fibrillation with ST-T wave changes suspicious for an acute myocardial infarction.  Serial serum troponin levels were mildly elevated.  The patient was admitted to the hospital for monitoring and treatment.  Echocardiography did not reveal obvious wall motion abnormality.  The patient was scheduled for direct current (DC) cardioversion but spontaneously reverted to normal sinus rhythm.  He was discharged the following day with outpatient follow up.

Admission for monitoring and treatment was medically necessary.  Patients presenting with atrial arrhythmia with ventricular rates up to 160 bpm require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia.  This patient presented to the hospital with chest pain and heart rates up to 190 bpm.  Moreover his initial systolic blood pressure was below 90 mmHg and ST-T wave changes were noted on ECG.  These findings are concerning and merit close monitoring and treatment.

An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen year period demonstrated an average length of stay of three days.  (Reference 1)  This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital.  The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Community acquired pneumonia (CAP). 
Treatment:  Inpatient admission. 
The insurer is denied coverage for inpatient admission.  The denial is upheld. 

The patient is a female with history of congestive heart failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), seizures and breast cancer.  The patient presented to emergency department (ED) with complaint of increased shortness of breath, productive cough with sputum and some chest and epigastric pain with vomiting.  Vital signs in ED temperature 98.3 F, heart rate 110, respiratory rate 21, and oxygen (O2) saturations 97 % on room air.  The patient was in no acute distress (NAD) lung exam Mild wheeze.  CVS S1 S2 N some epigastric tenderness noted Neuro exam was unremarkable. 

White blood cell count (WBC) was 8.7 K, Hgb 12, Electrolytes were within normal limits. BUN/ Cr 9/0.36 Troponin was negative.  Chest x-ray revealed (CXR) right lower lobe infiltrate with small effusion.  The patient was admitted for community acquired pneumonia (CAP).  The patient was treated with intravenous (IV) fluids, steroids, antibiotics, pain meds, and bronchodilators via duo nebs.

As per the history and physical documented, the patient was afebrile temperature 98.3F blood pressure 135/69 mm Hg, respiratory rate 20, heart rate 81, oxygen saturation 99 % patient in no acute distress, lung sounds revealed fine creptitus, abdomen exam - soft, non-tender; there was also a non-focal neuro exam.

The patient had elevated D Dimers, so she underwent CT Angiography to rule out pulmonary embolism (PE).  PE was negative.  Infiltrate and small effusion was noted.  The patient remained stable overnight and signed out AMA.  The patient was discharged on oral antibiotics and other medications.

This patient did not need acute inpatient hospitalization.  The patient was afebrile, hemodynamically stable.  WBC was normal, Electrolytes and BUN/ Cr were normal and Troponins were negative.  PE was ruled out by CTA.  The CURB 65 score was Zero.  This patient could have been placed in observation status while diagnostic testing and treatment were initiated.  The patient remained stable after admission.  Myocardial infarction (MI) and PE were ruled out.  The patient remained afebrile and hemodynamically stable after admission, was not hypoxic, and was in no acute distress.  There was no failure of outpatient treatment was documented.

This patient could have been discharged home on oral antibiotics and other meds after a period in observation and could have been followed up closely in outpatient setting.

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

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

Diagnosis:  Sinus tachycardia secondary to dehydration and anxiety.
Treatment:  Inpatient admission.

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

This patient is male with a history of depression and anxiety who presented to the Emergency Department (ED) referred by Psychiatry for complaints of weakness, lethargy, and slightly short of breath.  The patient reported poor appetite, nausea, poor oral intake and depressed mood.  The patient's electrocardiogram (EKG) showed sinus tachycardia with heart rate of 132 and possible right bundle branch block (RBBB).  The patient was seen by a cardiologist.  The patient was admitted to the Telemetry unit for sinus tachycardia secondary to dehydration and anxiety.  The patient's computed tomography (CT) scan of the head showed motion artifacts on several images with associated mild degradation of image quality and slight increased attenuation possibly representing hemoconcentration.  The patient's repeat exam noted heart rate of 108 bpm.  After treatment, the patient was cleared for transfer to the Psychiatric unit.

Based on the review of the medical record and literature, inpatient admission was not medically necessary to treat this patent's medical condition.  The patient presented with sinus tachycardia likely secondary to dehydration.  The patient's initial evaluation in the Emergency Room (ER) was unremarkable, including an unremarkable electrocardiogram (EKG).  Inpatient admission was not medically necessary for this patient.  The patient's care could have been provided in the observational setting in the hospital overnight, allowing for additional cardiac testing.  Further evaluation was warranted; however, inpatient admission criteria was not met.  The patient's thrombosis in myocardial infarction (TIMI) risk score was low, and there were no other high-risk comorbidities. 

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 inpatient admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Dementia.
Treatment:  Home Health Care/Personal Care Assistance services.
The health plan denied the personal care assistance services.  The denial is overturned.

The patient has a past medical history of dementia, hypertension, renal insufficiency, unsteady gait with a history of falls, and visual impairment who had been assigned personal care services at 10 hours/day, 6 days/week to total 60 hours per week.  The patient had a decline in health, mobility and mental status from previous assessment.  Patient was having increasing difficulty taking medication, sometimes taking more medication than prescribed, and sometimes not taking it at all.  The patient's primary care physician provided documentation that the patient no longer knows how to bathe, dress or toilet self and needs the assistance of another person.  The provider also noted the patient has fecal incontinence and needed assistance with toileting and hygiene.  It was also documented that the patient needed assistance with meal preparation and queues to eat. The PCP also noted the patient needed assistance with ambulation.  The health plan's determination of medical necessity is overturned.  The increase in PCA services is medically necessary.  The patient has a documented change in medical status, in particular, worsening of dementia and more difficulty with mobility with increasing falls.  Patient had two falls in the preceding 3 months, and PCP noted a need for increasing assistance with walking.  PCP reported increased fecal incontinence (which was not mentioned on the assessment tool) with the need for help with incontinence cares and help with personal hygiene.  The patient needed help with medication administration on a regular daily basis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Orthopedic/Musculoskeletal.
Treatment:  Inpatient Hospital.
The health plan denied the Inpatient stay.  The denial was upheld.

The patient is a female who was in her usual state of good health until she began to complain of left thigh pain.  There was no history of trauma, excessive exercise, or fever.  She was taken to the local emergency room, where she was noted to limp when bearing weight, but otherwise appeared well.  She underwent x-rays of the lower extremities, which were normal.  She was discharged to home with instructions to treat her pain with Motrin.  The following day, her pain and limp persisted, and she was felt to have a subjective fever.  She was told by her pediatrician to return to the emergency room, which she did.

In the emergency room, she was afebrile, and all of her vital signs were normal.  She again appeared well and was able to ambulate but complained of pain in the left leg with weight bearing.  She had no pain when not weight bearing.  She pointed to her left thigh when asked to localize the pain.  She appeared to have some weakness of the left leg and brisk reflexes at the left patella.  In the emergency room, she underwent blood tests and x-rays of the pelvis, bilateral lower extremities and feet, all of which were normal or negative.  She was admitted to the hospital at the acute level of care for a magnetic resonance imaging (MRI) scan of the lumbo-sacral spine.  While hospitalized she received intravenous Toradol.  The MRI scan of the lumbo-sacral spine was obtained, which showed no neurologic abnormalities, but did reveal some non-specific abnormalities at the growth plate, which were not likely contributing to her symptoms.  Her symptoms were improved, and she was discharged to home.

The health plan's determination of medical necessity is upheld, in whole.

The inpatient stay was not medically necessary for this patient.  This is a patient with a new onset of limp due to pain with weight bearing.  She has no fever or swelling or redness of any joint.  This history is strongly suggestive of a minor musculoskeletal injury.  Neither her history nor her physical examination suggested that her problem was neurological in origin.  Even if it had been, then inpatient admission for an MRI scan was not medically necessary, as the test could have been obtained at a lower level of care status.  An inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Uterine contractions.

Treatment:  Acute inpatient stay.

The insurer denied coverage for acute inpatient stay.  The denial is upheld.

This patient is female at over 30 weeks of gestation with a Dichorionic-Diamniotic pregnancy.  The patient presented to the Emergency Department (ED) with complaints of elevated blood pressure at home and "feeling funny and seeing spots".  The patient's blood pressure in the ED was 140/90.  The patient's fetal heart tracing for each baby was reported as category 1.  The patient was admitted for close blood pressure monitoring, and 24 hour urine collection.  Because of contractions seen on monitor, the patient was started on magnesium sulfate.  Progress note on the day of admission stated that the patient's laboratory evaluation was normal, and the patient's blood pressures were normal during her hospital stay. 

Based on the review of the medical record, the patient presented with one episode of mildly elevated blood pressure, no vaginal bleeding, no evidence of preterm labor and no ruptured membranes.  There was no evidence of fetal compromise.

Preeclampsia refers to the new onset of hypertension and proteinuria or hypertension and significant end-organ dysfunction with or without proteinuria after 20 weeks of gestation in a previously normotensive woman.  So, in this case, this patient's normal blood pressure and non-elevated urine protein indicated that this patient did not have preeclampsia.

According to MGC guidelines for hypertensive disorders of pregnancy, inpatient admission is indicated for one or more of the following conditions: eclampsia, preeclampsia with severe features, chronic hypertension or gestational hypertension that is severe (systolic blood pressure (SBP) greater than or equal to 160 mm Hg or diastolic blood pressure (DBP) greater than or equal to 110 mm Hg); hypertension (SBP greater than or equal to 140 mm Hg or DBP greater than or equal to 90 mm Hg) with conditions that include, but are not limited to, suspected fetal distress, hypertensive encephalopathy, cerebral infarction, intracranial hemorrhage, myocardial ischemia/infarction, heart failure, aortic dissection, acute renal failure, papilledema, retinal hemorrhage, microangiopathic hemolytic anemia, and seizure. 

In this case, this patient did not have any of the above.  Note that the patient was also admitted because of uterine contractions seen on monitor.  However, there was no evidence of preterm labor (i.e., cervical dilation).  This patient could have been observed for a few hours.  Once the provider ascertained that the patient's blood pressures were within normal limits with no evidence of preeclampsia and no evidence of cervical changes, the patient could have been sent home without the need for inpatient admission.  Thus, inpatient admission was not medically necessary to treat this patient's medical condition.

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 acute inpatient stay should be upheld.  The medical necessity is not substantiated.