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

This is a patient is a patient who was admitted for treatment of febrile seizure and a possible infection. The patient was seen at another facility and transferred to the treating facility.  He was described as well appearing but asleep. After transfer, the history and physical indicated that the child has experienced similar seizures when sick with common viral illnesses. He was noted to have a temperature of 39.2 but was on room air and while sleeping. A respiratory viral panel was obtained which was positive for rhinovirus/enterovirus.
The health plan's determination is upheld.
Febrile seizures and breakthrough seizures in children with ongoing seizure disorders are not uncommon in pediatric practice and rarely require hospital admission. In children with episodes of seizure that respond to anti-convulsant therapy, there is no need for admission for seizure monitoring. In children with pre-existing seizure disorders they are managed with adjustment of anti-seizure medications and outpatient follow-up. This child had a history of seizures, was not in status epilepticus, and was already on chronic anti-convulsant therapy.
Fever and concerns of invasive bacterial disease in children under 36 months of age has been a field of study for many years and the cornerstone of pediatric infectious disease evaluation and treatment. The assessment of a febrile infant or toddler can be a challenge. This child, however, was older than 36 months of age and was immunized.
This child had no vital sign abnormalities suggesting sepsis and was hemodynamically stable throughout his time at the outside institution as well as the admitting hospital. The child did not have bradycardia at any time. The child did not have any significant increase in respiratory rate suggesting SIRS. 
The child had an elevated leukocyte count on his initial evaluation but the CRP was normal. This child had no vital sign abnormalities suggesting sepsis. He was diagnosed with otitis media and given ceftriaxone and later found to be positive for rhinovirus/enterovirus. The child did not have bradycardia at any time. He did not have any significant increase in respiratory rate suggesting SIRS. The concerns for sepsis as the justification of the admission, are not reflected in the decision-making documented by the treating physicians. This child could have been given another dose ceftriaxone and had 24-hour follow-up with his primary care provider while awaiting urine and blood cultures. There was no treatment and no interventions that occurred during admission that could not been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented for inpatient rehabilitation substance use disorder treatment. She had a substance use disorder with alcohol class substance of abuse. The patient had no history of withdrawal seizures, delirium tremens or other episodes of severe withdrawal symptoms. She reported daily use of alcohol with up to one bottle of wine and/or one bottle of vodka four days per week or more. At the time of her presentation, the patient was not involved in any formal substance-related treatments or self-help recovery groups. She had received detoxification treatment prior to her admission for inpatient level substance-related rehabilitation treatment. Evaluation on admission for residential level services revealed a mental status examination that was free of severe psychiatric symptoms. She was generally motivated for rehabilitation treatment and had limited psychosocial support. She had no evidence of acute mania, thought disorder, psychosis, perceptual disturbance or severe cognitive impairment. She did not report suicidal or homicidal ideation. There were no somatic complaints other than post-acute withdrawal symptoms that were mild and insomnia.
The health plan's determination is upheld.
The clinical features and indicated treatment dimensions of this patient's alcohol use disorder, and co-occurring anxiety and depressive disorder with associated symptoms of anxiety and post-acute withdrawal symptoms, did not require or warrant the continued structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and ongoing diagnosis and treatment for an unspecified anxiety and depressive disorder. Moreover, the patient had been evaluated and cleared with regard to safety concerns and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or general medical complications that would have warranted continued inpatient level treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertensive gastropathy, status post esophagogastroduodenoscopy
Treatment:Inpatient admission 

Summary:
The patient underwent routine EGD and banding of the varix. There was no evidence of variceal bleed pre- and post-op. He did not complain any abdominal pain, nausea, or vomiting. He tolerated clear liquid diet well. He could have been safely discharged home after observation post-procedure in the recovery area.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a history of hyperlipidemia, borderline hypertension, cigarette smoking and a family history of coronary artery disease. He presented to the emergency department complaining of a sudden onset of chest pain, pain shortness of breath and palpitations that began after an emotional upset. His blood pressure was 128/72 millimeters of mercury (mmHg) with a heart rate of 90 beats/minute. His respiratory rate was 18/minute with a room air oxygen saturation of 99%. His cardiopulmonary exam was unremarkable, His electrocardiogram showed sinus rhythm with incomplete right bundle branch block; there were no acute changes. His serum troponin level was normal. His brain natriuretic peptide (BNP) level was normal. His creatine kinase level was minimally elevated; no myocardial band (MB) fraction was provided. His D-dimer was elevated; a chest computed tomography (CT) angiogram showed no evidence of pulmonary embolism. Chest x-ray showed no acute pathology. He was admitted to the hospital to rule out acute coronary syndrome. The following day he was asymptomatic. Serial troponin levels remained negative and there were no evolving electrocardiographic changes. An echocardiogram was unremarkable. Rest/stress myocardial perfusion imaging was performed. The patient demonstrated excellent exercise tolerance. There was no evidence of ischemia. He was discharged.

The health plan's determination is upheld.

This patient, with multiple cardiac risk factors, presented with chest pain that was suspicious for myocardial ischemia. Accordingly, monitoring until acute coronary syndrome (ACS) could be ruled out was a reasonable approach. On the other hand, he was hemodynamically stable, with normal serum troponin and BNP levels, and no ischemic electrocardiographic changes. There is no indication in the records provided that other potentially serious diagnoses were thought to be likely. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under lower level of care status. This approach has been shown to be safe and is in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes.
Moreover, given that the patient's repeat troponin levels were normal and he had no evolving electrocardiographic changes, the records provided do not indicate that there was a medical reason why stress testing was delayed until the following day.
In summary, the inpatient level of care was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld


Treatment: Inpatient admission, medications, monitoring

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

The patient presented with abdominal pain, nausea, and diarrhea.  He was afebrile and his vital signs were stable. The abdominal exam was benign. A white blood cell (WBC) count was 9.2 K.  A Computer Tomogram (CT) scan was read as enteritis or ileus. The patient was treated for gastroenteritis with intravenous (IV) hydration and antibiotics.  The following day, the patient felt better and insisted on leaving the hospital against medical advice (AMA).

MCG clinical indications for admission for gastroenteritis include having a suspected severe infection such as bloody diarrhea, severe abdominal tenderness, hemodynamic instability, severe vomiting, and severe dehydration. The patient did not have these conditions.

This patient had gastroenteritis and required intravenous hydration, Zofran, and Pepcid. The patient could have been given fluids and medication in the Emergency Room (ER) as an outpatient. If antibiotics were felt to be needed, they could have been given orally on an outpatient basis. The patient did not meet MCG criteria for admission for Gastroenteritis (M-170). He could have been managed at the observation level of care. 

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: Overturned

Diagnosis: Chest pain
Treatment: Inpatient admission

The proposed treatment was medically necessary.

The patient presented with new onset chest pain, suggestive of unstable angina. The patient had multiple risk factors for CAD, as well as a known history of coronary artery disease, requiring prior percutaneous revascularization. The ECG was unrevealing for acute coronary syndrome (ACS). There was a high index of suspicion for an ACS, and a cardiac catheterization was performed. The catheterization was abnormal, revealing an LAD lesion and the hemodynamic significance of the lesion was confirmed with iFR, so PCI was performed. Given the presentation, as well as clinical suspicion for an acute coronary syndrome/unstable angina, in the setting of prior CAD, s/p PCI, he would not be an appropriate candidate for an ED chest pain observation unit, and it would be consistent with the current standard of care that this patient be managed in an inpatient setting.  Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral gastroenteritis
 
Treatment: Inpatient admission, monitoring

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

The patient had previous abdominal surgery for diverticulitis and now presented with nausea and vomiting.  She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding.  There was no leukocytosis. A computer axial tomogram (CAT) scan was negative for bowel obstruction. She was diagnosed with a viral gastroenteritis. Testing for influenza A was positive.

The clinical indications for admission for gastroenteritis (M-170) include a suspected severe infection such as bloody diarrhea, severe abdominal tenderness, hemodynamic instability, severe vomiting and severe dehydration. The patient did not have these conditions.

This patient had a viral gastroenteritis. The treatment with intravenous (IV) hydration and antiemetics could have been given in the Emergency Room (ER). The renal function was normal. She did not meet MCG criteria for admission for gastroenteritis. She could have been managed as Observation status. 

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

Diagnosis: Stroke
Issue under review: Continued skilled nursing facility stay

Determination:
The Continued skilled nursing facility stay was not medically necessary.

As of a few days before the date of service under review, the patient was on regular diet, ambulating up to 90 feet with a custom AFO and requiring contact-guard, navigate 4 stairs with minimum/moderate assistance, requiring contact-guard/close supervision for feeding, transfers, requiring minimum assistance with dressing, bathing, toileting and grooming. The plan is to discharge home to live with the spouse. She has achieved a tangible level such that her care can continue at a lower level of care.

As stated above, the proposed continued stay in SNF was not medically necessary, and withholding the continued stay in SNF, in whole or in part, is not reasonably expected to affect the patient's health adversely. The patient will be better served in a lower level of care to meet her continued rehabilitation needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Accidental drug ingestion
Issue under review:  Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

Acetaminophen overdose is one of the more common means for attempting suicide, and, if not recognized early, can have dire and sometimes fatal consequences.  The most important intervention following early recognition is prompt treatment with Mucomyst (N-acetylcysteine) to prevent liver injury.  There is a nomogram available to guide management, and Poison Control can also be an invaluable resource for determining course of therapy. 

The first lab value for this child obtained four hours after ingestion was well below the treatment line on standard acetaminophen nomogram.  Ten hours later, the level was still well below the treatment line.  He was clinically mildly symptomatic with two episodes of vomiting.  However, thereafter he was able to tolerate his diet.  He was overall hemodynamically stable, afebrile, and in no acute distress.  While it was not unreasonable to monitor him in the hospital post-ingestion, he did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Pneumonia and CHF
Treatment:  Inpatient admission
The proposed treatment was medically necessary.

The patient presented with new onset CHF, was found to have a new onset cardiomyopathy with significantly reduced LV systolic function.  His ECG was abnormal with LBBB pattern.  The cardiac troponins were mildly elevated, indicating myocardial damage.  Nuclear stress test was abnormal, revealing reduced LV function and perfusion abnormalities.  The patient had comorbidities of diabetes, morbid obesity and obstructive sleep apnea.  Given his presentation and comorbidities, it would be consistent with the current standard of care that this patient be managed in an inpatient setting; therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient is a three-year-five-month-old male child that was taken to the emergency department (ED) with one-week history of cough and two-day history of vomiting and fever. 

Vital signs included temperature 38.3 to 39.2, heart rate 140, respiratory rate 26, and 99% saturation in room air. Examination was significant for no apparent distress, normal oral mucosa, clear lungs, benign abdomen, and non-focal neurologic exam. He was treated with a normal saline bolus and acetaminophen, and a chest x-ray was obtained. Laboratory evaluation was significant for elevated potassium (6.6, noted to be hemolyzed), metabolic acidosis (carbon dioxide [CO2] 16), and leukocytosis (white blood cell [WBC] 20.07 thousand [K]) with left shift (79.8% neutrophils and 5.1% bands). Rapid influenza testing was negative. Chest x-ray was normal. The patient was diagnosed with possible mild asthma exacerbation (based on the mother's history of childhood asthma exacerbated by viral upper respiratory infection [URI]) and dehydration. Admission orders included albuterol every three hours, ibuprofen as needed for fevers, and intravenous (IV) fluids at maintenance. 

The patient continued to have some vomiting overnight, but had no further fevers. His respiratory examination was unremarkable. He was not taking anything by mouth, so oral intake was encouraged. He did well over the course of the day. Repeat laboratory evaluation revealed improvement in metabolic acidosis with CO2 19 and decreased WBC count with no bandemia (WBC 9.53K). Quantitative immunoglobulins were ordered and were normal. He was tolerating albuterol every four hours. He was subsequently deemed stable for discharge home. Discharge diagnosis was upper respiratory infection complicated by reactive airway disease and dehydration, resolved. 


This child was taken to the ED because of fevers and vomiting. He had some cough the week prior. He had no documented respiratory distress or wheezing or oxygen requirement. He had laboratory indices suggestive of dehydration but no clinical findings to substantiate. He had fever and vomiting, and was not able to tolerate an oral challenge. He was subsequently admitted. While it was not unreasonable to monitor this child in the hospital to document adequate oral intake and continued clear respiratory exam, he had no signs or symptoms of sepsis, he had no oxygen requirement, and he was overall hemodynamically stable. He did not require acute inpatient management and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Gastrointestinal
Inpatient Hospital

This is a patient with a medical history of cirrhosis secondary to nonalcoholic steatohepatitis, portal hypertension complicated by esophageal varices and intractable ascites requiring frequent ascites, rectal varices, portal vein thrombosis on Lovenox, diabetes mellitus, sleep apnea, and asthma. She has had multiple large-volume paracenteses recently, despite maximal doses of furosemide and spironolactone. She presented for transjugular intrahepatic portosystemic shunt placement.  Lab results were notable for low hemoglobin of 7.8 grams per deciliter (g/dL) and low platelet count of 116 thousand per cubic milliliter (K/uL). The Model for End-stage Liver Disease (MELD) score was 8. She was classified as American Society of Anesthesiologists class IV. She had a large-volume paracentesis with removal of 8 liters of clear ascites and administration of 1 liter of albumin. She also had a transjugular intrahepatic portosystemic shunt (TIPS) placement with coil embolization of gastroesophageal varices. She had 9/10 chronic back pain and acute right neck pain after the procedure, but soon afterwards had removal of the intrajugular sheath, arterial line, and Foley catheter and was transported back to the floor in stable condition on 2 liters of oxygen/min via nasal cannula. The health plan's determination is upheld. The patient had a transjugular intrahepatic portosystemic shunt (TIPS) placement, coil embolization of gastroesophageal varices, and large-volume paracentesis. Her elevated Model for End-stage Liver Disease (MELD) score, which was designed to assess risk in patients undergoing TIPS, of 8 suggested that she was at moderate periprocedural risk; the American Society of Anesthesiologists (ASA) class of IV suggested an additional increase in MELD score. In the period after large-volume paracentesis, patients are at risk for circulatory and renal dysfunction; this risk is elevated in patients on diuretics. For these reasons, observation of the patient was warranted to ensure that complications such as peritonitis, encephalopathy, shunt thrombosis, systemic infection, and decline in hepatic or renal function did not develop after the procedures. The patient had an uneventful procedural course and lack of postprocedural complications, with discharge to home the subsequent day. However, the procedures performed and subsequent monitoring could have performed without inpatient status; none of the actions taken during the hospital stay required the inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient diagnosed with idiopathic short stature (ISS). The patient is on growth hormone (GH) therapy (Omnitrope and Nutropin). The patient GH stimulation test with glucagon and clonidine peaked at 22. Under review is the use of Norditropin for this patient's short stature.

The health plan's determination is overturned. Norditropin Flex Pro is medically necessary for this patient. 

According to the peer reviewed literature including consensus clinical guidelines for Idiopathic Short stature:

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines . Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

This patient has a pretreatment height less than or equal to -2.25 SD. The pretreatment height velocity was extremely poor even for the Tanner stage. The patient would not have been able to reach a normal adult height without treatment. The patient therefore met idiopathic short stature criteria for treatment with growth hormone. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission

The proposed treatment, inpatient admission, was not medically necessary.

This patient presented for evaluation of chest pain. The diagnosis of an acute myocardial infarct (MI) was ruled out by cardiac enzymes, which were negative, and the patient was referred for a nuclear stress test. Ischemia was ruled out by stress testing. There was no evidence of acute myocardial infarction, ACS, decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at an observational level of care.