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

Diagnosis: Cough, Fever, Shortness of Breath
Treatment: Inpatient admission
The proposed treatment of inpatient admission is not deemed medically necessary. 
This female patient presented to the ER for further evaluation/management of cough productive of mucopurulent sputum, fevers and dyspnea.  Intake vitals were afebrile, hemodynamically stable and non-hypoxemic on room air.  There was no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia.  Examination was non-focal with no significant abnormalities noted including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen.  Laboratory and ECG testing was also within normal limits with no significant abnormalities noted including no evidence of acute end organ damage.  Chest x-ray and chest CT revealed evidence of right upper lobe consolidation.  The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where she received treatment with broad spectrum IV antibiotics and supportive care with IV fluids.  She responded well to 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.  For these reasons, the proposed treatment of Inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the hospital with the complaint of abdominal pain, nausea and vomiting. She had comorbid health conditions of hypertension and gastroesophageal reflux disease (GERD). An outpatient abdominal ultrasound showed gallstones.  She underwent a laparoscopy.  The health plan's determination of medical necessity is upheld. Inpatient stay was not medically necessary because this patient had was clinically stable and did not manifest any of the above criteria for continued inpatient admission. While she did have an advanced intra-abdominal malignancy, her condition did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department (ED) with acute abdominal pain. The patient was initially discharged home but then readmitted due to recurrence of symptoms. Initial presentation of acute abdominal pain with vomiting occurred immediately after blunt abdominal trauma during a basketball game the day prior to admission. The patient underwent abdominal imaging (x-ray, ultrasound, and computed tomography [CT] scan) and labs which were all normal. Vital signs were afebrile and stable. The patient was discharged home after an overnight observation but represented to the ED later that evening with recurrence of acute pain and vomiting. During the second admission the patient had surgical and gastrointestinal (GI) consultations who agreed there were no indications for further intervention. The patient received intravenous fluids (IVF), pain medications, and anti-emetics. The patient was discharged home with improved condition and probable diagnosis of abdominal migraines, to trial Levsin medication and follow up with GI as an outpatient. The health plan's determination is upheld.

The inpatient admission requested was not considered medically necessary for this patient. This is a patient without medical history who presented with acute recurrent episodes of abdominal pain and vomiting. The workup in the ED, including several imaging modalities and labs, was normal. The patient improved with IVF and medication, and repeated physical exams noted that the patient had a non-surgical abdomen and displayed discomfort that was out of proportion to the physical exam findings. Given the patient's stability in laboratory and physical exam findings, as well as benign conclusions from surgery and GI consultation, it is reasonable that the case could have been handled at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned in Part

The patient has a diagnosis of Major Depressive Disorder (MDD). The patient's mental status examination on admission noted depressed mood, suicidal ideation, insomnia, low energy, anxiety, and low motivation. The patient expressed the belief that if not admitted to the current IHS patient believed that they  would commit suicidal. Prior to this current hospitalization, patient showed functional impairment in several areas: not paying her bills; lost volunteer job; was homeless after having been evicted. Patient has required at least 4 prior IHS admissions. Patient was sexually abused as a teenager. Patient received pharmacological treatment. Additionally, the patient received individual and group therapy, social work services, and discharge planning.

The health plan's determination is overturned in part. The two additional days past the original days approved by the health plan are necessary to document that the patient had improved sufficiently from the patient's chronic suicidality. A team progress note noted no suicidal ideation, as well as documenting that the patient was future oriented, compliant with her medications, and was attending meetings.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ehlers-Danlos syndrome
 
Treatment: Outpatient physical therapy

The insurer denied additional physical therapy. The denial was reversed

Ehlers Danlos syndrome is a genetic connective tissue condition that is characterized by varying degrees of joint hypermobility that causes joint dislocations and musculoskeletal pain.  Recommended treatments are physical therapy, bracing, medications and orthopedic surgery.  The current referenced literature indicates general orthopedic surgery should be delayed in favor of physical therapy and bracing, and non-operative treatment should be maximized prior to surgical intervention.  The documentation indicated that the patient had previously attended physical therapy since 2018.  The most recent physical therapy progress report from 2019 noted that the patient made minimal gains and the patient had improved ability to activate minor lower extremity musculature appropriately.  The patient lacked appropriate muscle strength and endurance to maintain neutral lower extremity, pelvic, trunk and upper extremity alignment and a variety of sitting and in standing for more than 2 minutes.  The patient continued to present with mild forward head posture, moderate increase in thoracic kyphosis extending through the lumbar spine, severe bilateral hip flexion with internal rotation, severe bilateral tibial internal rotation and severe ankle inversion.  The patient made minimal gains through consistent continuous therapy.  The patient's progress has been appropriate given her pathology due to requisite protocol of progressing slowly and appropriately with the focus on stability. The patient also made improvement in mat exercises and ball exercises.  It is noted that the patient's slow improvement in therapy is appropriate for the patient's diagnosis.  The patient requires slow progression in physical therapy to help increase core stability and strength in a manner that will prevent subluxation, joint damage and pain.  However, the patient continued to have deficits to include mild forward head posture, moderate increase in thoracic kyphosis extending through the lumbar spine, severe bilateral hip flexion with internal rotation, severe bilateral tibial internal rotation and severe ankle inversion.  

Therefore, continued physical therapy would be appropriate.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of multiple medical problems including hypertension, hyperlipidemia, coronary artery disease, bipolar disorder, anxiety and seizure disorder. On 11/30/18 she underwent permanent pacemaker implantation for bradycardia.  On 12/3/18 she presented to the emergency department complaining of chest pain.  The health plan's determination of medical necessity is upheld.  She was hemodynamically stable, with normal cardiac biomarkers and no ischemic electrocardiographic changes.  She did not require intensive monitoring or infusion of intravenous cardioactive medications.  With regard to her chest pain the care this patient received did not require an inpatient admission and could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department (ED) via Emergency Medical Services (EMS) after a witnessed generalized tonic-clonic seizure lasting 5-10 minutes at home.There was no known trauma. He has had 1 week of a cough, but no fever or dyspnea.

The health plan's determination is upheld. The inpatient stay was not medically necessary. This patient demonstrated no hemodynamic instability and no focal neurological deficits. While having had a recurrent seizure, he had a known EEG diagnosed history of epilepsy with known medical noncompliance as the likely cause for break through seizures and not medical therapy failure. While described as sleepy on arrival, the alteration in his mental status was described as postictal. Monitoring was necessary but this could have occurred at a lower level of care and did not require admission to inpatient care.
Appeal type: Medical necessity
Decision: Overturned

The patient presented with vomiting, diarrhea, and refusal to take fluids. The patient was well until the day prior to presentation when vomiting and diarrhea developed. Vomiting was described as projectile and with every feed. The patient then developed diarrhea approximately every hour, and the patient's mother noted occasional streaks of blood in the stool. The patient's mother brought him to the emergency department for evaluation of continued vomiting and diarrhea. The health plan's determination is overturned. 
This patient presented to the emergency department with a substantial amount of vomiting and diarrhea and continued to have vomiting despite appropriate and aggressive treatment in the emergency department and was refusing to take oral fluids. The patient was dehydrated as indicated by tachycardia and was described as being weak appearing. Inpatient admission was required for continued intravenous fluids to both replace fluid losses and account for inadequate fluid intake. The required bowel rest and close monitoring with additional intervention as needed.
The decision-making at the time of admission for this patient was consistent with the patient's age, the presence of significant and persistent vomiting and diarrhea, the continuation of his symptoms despite appropriate treatment in the emergency department, and the need for continued hydration and ongoing monitoring for potential deterioration of clinical status. Inpatient hospital admission is necessary for patients with vomiting and diarrhea that is persistent and combined with an inability to maintain oral hydration.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain, past medical history of hyperlipidemia and hypertension

Treatment: Inpatient admission, diagnostic testing and medication management

The insurer denied the inpatient admission. The denial was upheld

This patient was seen in the emergency room for bilateral lower extremity pain/weakness associated with low back pain x8 days.  The patient reported she had been seeing a physician who was treating her with steroids and a muscle relaxer.  She had a lumbar epidural steroid injection (LESI) two weeks prior.  The patient reported not being able to walk for the previous 24 hours.   The MRI revealed moderate central canal stenosis with bilateral foraminal stenosis at L4-5, due to herniation, bulge, and facet arthropathy.  Upon examination the patient had full range of motion, equal pulses and upper and lower extremities, decreased right leg extremity range of motion.  The was admitted for pain control and IV Decadron. The patient had no focal deficits or neurologic compromise.  The patient was requesting surgery in the inpatient setting as she felt she was unable to function with her current level of pain and radiculopathy.  The patient had a L4-5 right hemilaminectomy and microdiscectomy.  There was post-operative resolution of right leg pain.  

The guidelines state that inpatient admission for back pain is indicated for one or more of the listed criteria including cauda equina or conus medullaris syndrome including bowel dysfunction, bladder dysfunction, saddle anesthesia, neurologic abnormality suggesting distal spinal cord impingement, progressive or severe neurologic deficit, spine fracture with significant damage or threat of damage, suspected spinal infection, severe pain requiring acute inpatient management.  Severe pain requiring acute inpatient management following being documented, including, pain unresponsive to non-opioid analgesia and non-pharmacologic treatment, oral, transdermal or submucosal route not appropriate or not sufficient, anticipated titration not appropriate for lower level of care, due to frequency monitoring needs, suspected new or deteriorating disease process as etiology, palliative procedure planned that necessitates inpatient care for assessment and monitoring needs.  

There was no documentation of one or more of the indications for inpatient management of low back pain.  There was documentation that the patient had an epidural steroid injection two weeks prior, was experiencing low back pain that the pain reported was intolerable.  The patient was seen in the emergency department and treated for pain. The physician documented that he would prefer to perform low back surgical procedure as an outpatient, to assess for improvement of the patient's condition with conservative treatment. However, the patient insisted on having the L5 nerve root compression surgery as an inpatient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/ Gastrointestinal (Gastroenteritis resulting in dehydration)
Treatment: Inpatient Hospital

Summary: This patient without a significant past medical history presented to the Emergency Department (ED) by ambulance @ 15:03 with a history of non-bloody, non-bilious vomiting for two days, (7 episodes total), decreased appetite and lethargy. There was no reported weight loss, fevers, diarrhea, sick contacts or difficulty breathing. He was given D10 25ml and three 100cc normal saline boluses followed by D5 normal saline @ 30cc/hour. In addition, he received a single dose of ceftriaxone. He was evaluated by Pediatric Surgery that noted no need for surgery at that time. The decision to admit him occurred @ 19:54. Serial lactate levels showed a drop to 7.2 by admission. He was noted to be more alert and active and was breastfeeding successfully in the ED. After admission, his intravenous (IV) fluids were changed to D5 1/2 normal saline @ 21cc/hour. He continued to tolerate feeds and IV fluids were stopped at 07:57 the following day. He did not vomit after admission and his heart rate varied from 132-142. No additional antibiotics were administered. He was discharged home @ 12:27 for outpatient follow-up.

The insurer has denied coverage for the acute inpatient hospital admission as not medically necessary. The denial was reversed.
 
This patient appears to have viral gastroenteritis with self-limited vomiting for two days resulting in significant dehydration and poor tissue perfusion that responded to aggressive intravenous repletion. His physical exam and laboratories despite relatively normal vitals were extremely concerning. He certainly had laboratory abnormalities at presentation that persisted to the time of admission to the ward showing persistent lactic acidosis to merit the inpatient acute care setting. Although he did not vomit further in the ED, a period of monitoring was required. Clearly this patient was assessed as moderately dehydrated on presentation that improved by the time of admission to his ward bed. He was adequately resuscitated in the ED to improve his clinical appearance prior to the decision to admit and continued to receive IV fluids with the ability to tolerate fluids to some extent. His care was appropriately delivered given the severity of his initial presentation with volume repletion in the ED followed by continuous hydration in a monitored setting with reassessment for improvement in his lactic acidosis. Although the patient did not vomit further, there was no expectation that he would maintain his hydration without IV supplementation. After a brief period of observation and monitoring, this patient was safely discharged with outpatient follow-up. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse 
Treatment: Inpatient Treatment

Summary:
Inpatient admission is medically necessary. The requested Inpatient admission and treatment could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using heroin with IV administration on a daily continuous basis; and use of other substances of abuse including cannabis and cocaine that did warrant inpatient level detoxification and withdrawal management and monitoring; detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission.  Moreover, the patient had persistent withdrawal symptoms, and, the patient's social environment was not conducive to detoxification, and the patient struggled with withdrawal symptoms during the time interval under review in the context of limited insight, impaired judgment and poor control of impulses.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Irreversible pulpitis
Treatment: General Anesthesia
The general anesthesia was medically necessary. 
Profound pulpal anesthesia after a successful inferior alveolar nerve block can be difficult to achieve when the clinical condition is a pulpal diagnosis of symptomatic irreversible pulpitis. One of the primary challenges faced by the clinician attempting to remove mandibular teeth is the accomplishment of a successful anesthesia in patients with irreversible pulpitis using the inferior alveolar nerve block (IANB). This poses major difficulty from a clinical point of view as an inadequately anesthetized hot tooth with severe pain will not only lead to elevation of apprehension by the patient but also cause distress in the practicing clinician. Studies reported that the failure ratio of a single IANB block injection of local anesthetic in patients with irreversible pulpitis ranges between 30 and 90 percent. Deep sedation is necessary to provide pain relief, sedation, and memory loss.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchiolitis
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.
The patient is a little boy born at 34 weeks' gestation with prior history of wheezing with upper respiratory infections. He presented to the ED with cough, fever, and congestion. He had been seen by his pediatrician the day prior and prescribed nebulized albuterol, with no improvement. 
The patient's vital signs included temperature 39.2, heart rate 168, respiratory rate 38, and oxygen saturation 98% in room air. Laboratory evaluation revealed positive rapid RSV (respiratory syncytial virus). His chest x-ray was unremarkable. He was treated with three Duonebs, Decadron, and suctioning, with resultant clear lungs. However, he remained tachypneic with increased work of breathing (belly breathing, mild intercostal retractions), so he was admitted to the pediatric floor with diagnosis of RSV bronchiolitis with asthma exacerbation. 
The patient's admission orders included albuterol every four hours, enteral steroids, ranitidine for GI (gastrointestinal) protection, nasal suctioning, and regular diet for age. He did well overnight, with his last fever. The family was given asthma teaching and an asthma action plan. The baby was monitored for a second night and then deemed stable for discharge, to complete a five-day course of steroids and continue albuterol every four hours.   
This baby with history of reactive airways disease contracted RSV and subsequently developed bronchiolitis. He presented with fevers and increased work of breathing. He was admitted for management of RSV bronchiolitis with asthma exacerbation. He remained hemodynamically stable with no oxygen requirement, taking his bottle well, making adequate wet diapers. While overnight monitoring was reasonable, this little boy did not require acute inpatient status, and he could have been safely managed at a lower of care.
Appeal type: Medical necessity
Decision: Upheld

The patient underwent left medial uni-compartment knee replacement surgery. The procedure was tolerated well and there were no documented complications. The patient was discharged the following day. The subject under review is the medical necessity of the surgery that was performed.
The health plan's determination is upheld.

The requested left knee partial replacement surgery is not medically necessary for this patient. The rationale for this determination is based on the current, peer-reviewed literature on medial compartment knee arthritis and a review of the provided medical records for the patient in question. First, the clinical practice guideline published by the American Academy of Orthopedic Surgeons on the treatment of knee osteoarthritis in 2014 outlined a series of conservative treatment modalities that are effective and proven by peer-reviewed studies. These treatments are recommended prior to surgical intervention. The records provided in this case do not document any of these conservative treatments prior to the patient's operation on 1/23/19. In addition, the operative dictation provided does not details any indications for the surgery nor does it contain any of the non-surgical interventions attempted prior to surgery. Therefore, based on the supplied records, the medial compartment arthroplasty performed on this patient is not medically necessary because the care rendered was not consistent with the peer-reviewed orthopedic literature with reference to the treatment of medial compartment knee arthritis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major depressive disorder
Treatment: Continued inpatient admission
The continued inpatient admission was medically necessary.  
The patient represented an acutely elevated risk of dangerous behaviors and there was no less-restrictive treatment environment appropriate.  The acute risk factors of depression with the chronic risk factors of dangerous behaviors suggest that the patient would have been at an acute risk of self-injurious behaviors (including but not limited to suicide) were he to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.  
The patient represented an elevated risk of dangerous behaviors including self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore the treatment was medically necessary.  While the patient was not endorsing active suicidality or homicidality, the patient remained depressed.  The patient had multiple static risk factors for potentially dangerous behaviors including prior suicide attempt, chronic pain, and diagnosis with a severe mental illness.  Therefore the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained depressed was an acute risk factor for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.