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

Endocrine / Metabolic / Nutritional
Pharmacy / Prescription Drugs

The patient is a female with a history of (h/o) growth hormone deficiency as noted by 3 failed growth hormone stimulation test (GHST) results and likely Noonan Syndrome. The patient was referred to endocrinologist multiple times for short stature and poor growth. She had peak growth hormone (GH) levels of 5.53 nanograms per deciliter (ng/dl), then she had peak GH of 9.24 nanograms/milliliter (ng/ml). Last year repeat GHST results showed peak GH of 6.91 ng/ml.
Genetic testing showed a normal microarray but heterozygous mutation which may be associated with autosomal dominant Noonan-like syndrome.
Her past medical history (PMH) was notable for being born at 36 weeks gestation at a weight of  4 lbs. 10 oz., as well as a patent ductus arteriosus (PDA).
The physical exam was notable for Tanner 3 breast tissue. Growth velocity (GV) of 6 centimeters per year (cm/year) at Tanner 3 puberty. Magnetic resonance imaging (MRI) of the brain was normal.
The recommendation by the endocrinologist is for GH due to a diagnosis of "Noonan-Like Syndrome" and Growth hormone deficiency. This was denied by the health plan. The subject under review is the medical necessity of the growth hormone.

The health plan's determination is overturned.

The treatment with Norditropin is medically necessary for this patient based on the criteria of GH deficiency, Noonan syndrome, and slow growth rate for the stage of puberty.
In determining medical necessity, it must be taken into account the patient's diagnosis of growth hormone deficiency (GHD) and slow growth rate based on where the child is in puberty. Pubertal growth rates for girls are usually closer to 6.7 -8.3 cm/year at this stage of puberty. Furthermore, the child has GHD and possible Noonan Syndrome which are indications for GH.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological 
Treatment: Inpatient hospital 

The patient is a female who had a laparoscopic hysterectomy secondary to a pelvic mass. The surgery went well with minimal blood loss. There were no complications. She did well postoperatively. Vital signs were stable. She was admitted as an inpatient. She was discharged the following day doing well. The foley catheter was still intact and she was to follow up as an outpatient. The inpatient hospital admission is under review. 

The health plan's determination is upheld. The inpatient admission was not medically necessary. The patient had a routine and uncomplicated laparoscopic hysterectomy. She had no significant morbidity and the hysterectomy was scheduled. The blood loss during the procedure was minimal. Vital signs were normal and stable throughout her stay. There were no respiratory nor cardiac complications. She could have been monitored for extended care, less than 24 hours. There was no documentation to support the need for inpatient hospital admission. She had no severely abnormal labs, no operative complications nor postoperative complications. On the contrary, the patient did well and was discharged the following day for follow up as an outpatient. She had no infection, hemorrhage nor hemodynamic instability. All of her care could have been performed at a lower level.
Appeal type: Medical necessity
Decision: Overturned

This is a female with known sickle cell disease brought in by her mother with bilateral flank and back pain which started the day prior to presentation. She also complained of chest pain that also started on the day of presentation. Pain was severe, 9/10 intensity and worsened by movement and deep breathing. This pain was only relieved mildly by the use of Tylenol and heating pads. There was no associated fever, cough, abdominal pain, headache or weakness. Her baseline hemoglobin is 8.3. Last emergency room (ER) visit for vaso-occlusive crisis was five months prior and resolved with Motrin. About two weeks prior she was treated for febrile illness with intravenous (IV) levofloxacin for two days. Daily medications include folic acid.
In the ER she received a bolus of saline. Pain persisted and she initially received ibuprofen then subsequently ketorolac and morphine with some relief. A maintenance IV infusion was started. After ER management with Motrin, IV morphine, IV Toradol, IV fluids and application of warm packs, the patient was still complaining of pain, so she was admitted to the floor for further rehydration and pain control. While in ER after these treatments, she continued, per Registered Nurse (RN) notes, to complain of chest pain. Laboratory studies upon admission were unremarkable given her underlying sickle cell disease. Chest x-ray was also negative. Admission vital signs and physical exam were unremarkable. On the first day of admission she received IV ketorolac every six hours around the clock, Tylenol as needed (PRN) and she received one dose of morphine to achieve pain control. She progressively improved to being pain-free by day two of admission and maintenance fluids were discontinued. The patient remained afebrile throughout admission and tolerated age appropriate diet. She was cleared for discharge home upon resolution of pain. She was instructed to follow up with hematologist six days after discharge. The patient's mother was instructed to return for fever, inability to tolerate fluids, or worsening pain.

The health plan's determination is overturned.

The requested health service/treatment of inpatient stay is medically necessary for this patient. This patient with known sickle cell disease presented pain that was refractory to acceptable ER management. She received IV hydration and PO analgesics without good pain control, so she was stepped up to IV pain medicine which included opiate therapy. Despite a dose of morphine in the ER patient, her pain, though initially improved, returned. At that point the decision was made to admit to inpatient as the supposition was that she needed to continue her IV morphine and IV Toradol to adequately control her pain. For these reasons, admission to inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer - Pancreas Cancer 
Treatment: Skilled Nursing Facility 

The patient is a male admitted secondary to weakness and fatigue with recent diagnosis of cyst of pancreas, diabetes mellitus type 2, renal insufficiency, atrial fibrillation, anemia, edema, generalized weakness, hypertension, gastroesophageal reflux disease, hypotension, diarrhea and pressure ulcer of left ankle stage I. The patient was admitted for skilled services secondary to weakness and fatigue. The health plan denied the skilled services as not medically necessary. 

The health plan's determination is upheld. 

Based upon the records provided the patient has multiple medical problems including fatigue secondary to his underlying diagnosis. There was significant improvement with physical therapy over the course of therapy. Recently, the patient was able to ambulate sufficiently to maintain in an apartment. There was no notation in the record that the patient would need chronic long-term custodial care. It is reasonable to say that in 2 months of physical therapy the patient did have significant improvement however, there was a notation according to the appeal that the patient's home situation was not ideal in regards to continuing his outpatient care. There is a notation that the patient did not have a good family support system that was reasonably close to help him out. However, there was no specific medical necessity for ongoing inpatient skilled care. The patient's level of function is adequate for a home situation. Further treatment and therapy can be continued as an outpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Hypertensive Emergency, Transient Ischemic Attack

Treatment:  Inpatient Admission

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

This is a male patient with a history of chronic kidney disease stage lll and hypertension.  He presented to the Emergency Department with complaints of left sided numbness on his face, arm, and leg.  The patient was admitted however for management of hypertensive emergency and transient ischemic attack (TIA).  His presenting blood pressure was 202/116; he was treated with hydralazine.  He was consulted by Cardiology and Neurology.  He had a cardiac stress test, which revealed an ejection fraction of 64% and was negative for angina.  Laboratory work up was performed with results within normal limits.  The patient was discharged with outpatient follow up instructions. 

From a neurological standpoint, the patient developed transitory left side numbness without evidence of acute neurological condition or evidence of acute stroke.  The patient's condition could be managed in a different setting.  Literature does not recommend an inpatient admission in the absence of significant findings on imaging, laboratory testing or objective examination that cannot be managed at a lower level.  As noted above, the patient had no evidence of acute stroke on objective examination or imaging.

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

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:  Shortness of breath, pneumonia 
Treatment:  Inpatient admission 
The proposed treatment was not medically necessary. 

The patient is a male with history of previous drug abuse with shortness of breath for few days who presented to emergency room.  The patient was admitted to acute in-hospital for the management of pneumonia.  The patient was started on intravenous (IV) antibiotics.  The patient's condition improved and the patient was discharged home with oral antibiotics. 

At the time of admission, the patient was hemodynamically stable.  The patient's physical exam was within normal limits.  The blood work was within normal limits.  The chest x ray revealed pneumonia.  There is no clinical documentation of trial and failure as outpatient as well as observation level of care.  The patient had a Curb-65 score of one, which makes this patient appropriate for outpatient level of care.  The patient was able to take oral medications.  The acute in-hospital level of care was not medically necessary.  The appropriate level of care would be outpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a past medical history of Parkinson's disease, osteoarthritis, low back pain and complications from a right knee replacement.  The patient required right total knee replacement revision surgery due to disruption of her initial surgery because of a fall.  She was hospitalized for this procedure.  She had an assessment tool performed for Personal Care Assistant (PCA) services.  She was assigned 7.5 hours/day, 7 days/week to total 52.5 hours per week.  The patient had another fall while trying to ambulate alone and had a dislocation of patella of the right knee and was placed in a knee immobilizer.  The patient's primary care provider (PCP) requested an increase in PCA service hours to 12 hours/day, 7 days/week to total 84 hours per week.  The patient had an assessment tool performed with no change in status of any of her activity needs assessment.  There was an initial adverse determination notice of non-approval of increase in PCA services.  There was a letter from the health plan of final determination of the denial for 12 hours/day, 7 days/week to total 84 hours/week. The patient's orthopedic provider recommended an increase in PCA service hours to 24 hours per day to aid the patient with ambulation, locomotion and toilet transfer.  At a visit with orthopedics, it was again recommended that the patient apply for an increase in hours for PCA services due to her risk of falling and further injury with tasks in her home.  At issue is the medical necessity of an increase in  PCA services.
The health plan's determination is overturned.  The increase in consumer directed personal assistance program services:  12 hours per day, 7 days per week for a total of 84 hours a week is medically necessary.  The patient has a history of osteoarthritis and had a right knee replacement.  After this surgery the patient had a fall while trying to ambulate and needed to have revision of her right knee replacement.  The patient had another fall with the complication of a dislocation of the right knee that had previous replacement and revision.  The patient did not have a change in her assessment tool although the patient had more difficulty in her ability to ambulate, walk and transfer from the toilet.  The PCP and orthopedic provider felt it was medically necessary for an increase in PCA hours, with the PCP requesting 12 hours/day, 7 days/week and the orthopedist requesting 24 hour/day, 7 days/week.  The patient did live with her daughter, but her daughter works and could not provide informal care outside of the recommended PCA service hours recommended by the health plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Orthopedic/Musculoskeletal
Treatment:  Home Health Care

The patient is a female who lives with her son with past medical history of osteoarthritis, hypertension, diabetes mellitus type 2, previous hip fracture with need to ambulate with walker, dementia with hallucinations, depression and urinary incontinence.  The patient was assigned Level 2 personal care aide (PCA) services at 8 hours/day, 5 days a week and 7.5 hours/day, 2 days per week base on assessment tool performed on early 2019.  There was request for approval of Level 2 PCA services 2-12 hour split shifts/7 days per week to total 168 hours/week. The plan denied this request.  There were home visits by primary care physician (PCP) on two occasions indicating the patient's medical history, as documented above.  The patient saw a psychiatrist with documentation of above medical diagnoses and notes that patient's son would be moving to Florida.  The patient had a Uniform Assessment System - New York Comprehensive Community Assessment Report performed in the spring and again in the end of summer.  With task of managing finances and locomotion the patient's level of support worsened from maximal assistance to total assistance.  With tasks of personal hygiene and dressing upper extremity/lower extremity (UE/LE) the level of support changed from extensive assistance to maximal assistance.  The patient's bed mobility and phone use level of support changed from limited to extensive, while task of eating changed from independent to extensive.  In the most recent assessment it was noted the patient had history of altered mental status, hallucinations, increased weakness, dizziness, shortness of breath and poor balance with walking with walker.  The patient's son wrote a letter to insurance noting the patient had left the gas on the stove on, allowed water to run over and had fallen when using her walker.

The health plan's determination is upheld.

No, there is no documentation from the PCP or psychiatrist of the patient's overnight needs that would require 2-12 hour split shift personal care aides.  There has been a change in status from the first assessment to the time of the assessment with no change in the amount of PCA service hours.  The patient had worsening of tasks, as noted above, from the first to the second assessment.  In addition, since the most recent assessment there has been a change in the status of the patient's informal helper.  The patient's son is moving to Florida, and, therefore, would be unable to continue in caring activities.  There should have been an increase in PCA service hours from the first assessment, and the most recent assessment should have noted the patient's informal helper would not be available. (The report indicated she had an informal helper greater than [>] 12 hours per day).  The medical records provided support the patient's diagnoses, however, they do not specify the medical necessity for level 2 PCA 12 hrs. per day (split-shift) services.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hyperemesis
Issue under review:  Inpatient admission

Determination:  The Inpatient admission was medically necessary.

The patient is an adult G1 female who presented to the ED at ten weeks zero days with severe hyperemesis and weight loss of seven pounds.  She had nausea and vomiting for five weeks and had failed outpatient management including multiple visits and one the day prior to admission and prior treatment with intravenous fluids, Reglan, doxylamine vitamin B6, and Pepcid.  At this time she stated she was unable to tolerate anything by mouth.  

The patient was admitted to the maternity unit and received intravenous (IV) hydration, IV Pepcid, IV Zofran, and vitamin B6.  Her condition improved, and she was discharged home on hospital day #3.  

The facility contends that the hospitalization was medically necessary and cites MCG 22nd edition Hyperemesis Gravidarum ORG M-195, admission indicated for hemodynamic instability, vomiting that is severe or persistent, dehydration that is severe or persistent, other condition requiring inpatient admission.  The health plan contends that the admission was not medically necessary due to lack of hemodynamic instability, hypoglycemia, acid base disorder, or endocrine disorder and cites MCG 23rd Edition Hyperemesis Gravidarum ORG M-195 (ISC) and General Admission Criteria GRG: CG-GAC (ISC GRG).  

The patient had been to the hospital on numerous occasions, could not keep anything down, and had failed outpatient management.  The American College of Obstetricians and Gynecologists (ACOG) practice bulletin clearly states that "When a woman cannot tolerate liquids without vomiting and has not responded to outpatient management, hospitalization for evaluation and treatment of dehydration and electrolyte imbalance is recommended."  Therefore, based on this national practice guideline the hospitalization is recommended and the admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Back pain
Issue under review:  Inpatient admission

Determination:  The Inpatient admission was not medically necessary.

The patient is an adult female with back pain.  

Magnetic resonance image (MRI) of lumbar spine showed L3-L4, Grade I (almost Grade II) spondylolisthesis of L3 on L4, which causes an unroofing of the dorsal aspect of the intervertebral discs which maintains relationship with L4 vertebra.  L4-L5 shows mild posterior bulge, mild central stenosis and bilateral lateral recess stenosis.  The remaining lumbar levels are unremarkable; the distal aspect of spinal cord is normal in appearance; the abdominal aorta is normal caliber; incidental note is made of multiple renal cysts.

Later MRI of the cervical spine showed heterogeneous cervical spine on inversion recovery sequences appears artifactual with no confirmation on additional sequences; C3-C4 and C5-C6 minimal disc bulges with no central stenosis, cord radicular or foraminal impingement. 

Planar fluoroscopy and tomographic reconstructed images were performed to ensure appropriate positioning for surgical hardware.  Electrocardiogram (EKG) revealed sinus rhythm with left atrial enlargement.  Neurosurgery admitted the patient to inpatient. 

Neurosurgery performed L3-4 laminectomy with bilateral foraminotomies; L3-4 non-segmental instrumentation with stereotactic-guided pedicle screws; L3-4 posterolateral arthrodesis; autograft and allograft bone fusion; stereotactic-guided placement of hardware.  Preoperative diagnosis was L3-4 stenosis with spondylolisthesis; postoperative diagnosis: L3-4 stenosis with spondylolisthesis.

There is no clinical evidence of post-operative complications or loss of function requiring inpatient stay.  The patient had incision pain with no leg pain and no clinical neurologic deficits.  In-hospital stay was not medically necessary.

Marfil-Garza et al. in 2018 found prolonged length-of-stay (LOS) is associated with increased mortality and other poor outcomes (2). 

Lingsma et al. in 2018 conducted a study and observed a 3.1% mortality rate, 7.8% readmission rate (in survivors) and 20.8% long LOS rate among 4,327,105 admissions.  Mortality and LOS were correlated at the patient and the hospital level.  A patient in the upper quartile LOS had higher odds of mortality (odds ratio = 1.45, 95% confidence interval 1.43 - 1.47) than those in the lowest quartile (1).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Gastrointestinal
Treatment:  Inpatient hospital stay

The patient has decompensated cirrhosis with a history of ascites and hepatic encephalopathy who presented to the Hospital emergency room with a one day history of upper abdominal pain and repeated vomiting.  Exam revealed no acute distress but a low blood pressure 93/38.  The patient was noted to be slow to respond.  Evaluation included a computed tomography (CT) of the abdomen that revealed a cirrhotic liver, splenomegaly, ascites and dilated small bowel.  This raised the concern for small bowel obstruction.  Labs revealed an elevated ammonia and also urinalysis revealed positive leukocyte esterase and pyuria suggestive of urinary tract infection.  The patient was admitted and treated with intravenous antibiotic, Ceftriaxone.  There was no notation of a paracentesis.  The patient was treated for hepatic encephalopathy and improved and was discharged two days later.  The patient is being evaluated for a liver transplant and has severe end stage liver dysfunction.  The health plan's determination of medical necessity is overturned in whole. 
The patient had severe liver disease with decompensation with ascites, hepatic encephalopathy, jaundice with bilirubin 3.7 and low albumin 2.5 and coagulopathy with protime 16.4.  These findings of end stage liver disease place the patient at increased risk of progressing to liver failure with associated increased mortality rate, which can be precipitated by the urinary infection.  There is also concern that the CT scan revealed an early small bowel obstruction as the cause of vomiting. The dilated small intestine could also be from an ileus secondary to the urinary infection.  The patient could also have had spontaneous bacterial peritonitis; although a diagnostic paracentesis was not done.  In either event, it was appropriate to admit the patient to the acute care hospital for treatment including intravenous antibiotics and to follow for possible bowel obstruction or ileus.  Inpatient care is medically necessary to treat this patient with decompensated cirrhosis to lower the risk of progression to liver failure and death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headaches; blurred vision 
Issue under review: Inpatient admission 

Determination: The inpatient admission was not medically necessary. 

The patient is an adult female. She presented to the emergency ward with the complaint of headaches and blurred vision for one month, and right ptosis that had started on that day. She was suspected of having myasthenia gravis and was started on Mestinon and prednisone. CT brain, MRI brain and MRA brain were negative. 

The patient presented with ptosis and facial weakness and was suspected of having myasthenia gravis. There was no evidence of myasthenia gravis crisis or stroke. The diagnostic studies, monitoring and treatment could have been safely and effectively provided at a lower level of care.