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

Skin Disorders: other
Pharmacy/Prescription Drugs

The patient is a male with chronic idiopathic urticaria with some vasculitis changes. The patient has tried and failed fexofenadine (Allegra) at four times the normal dose as well as Singular. The patient previously tried and failed four times the normal dose of loratadine, but fexofenadine provided slight better (but inadequate) control of his condition. Cetirizine has also been tried and failed. Previous treatments tried and failed include Dapsone, Colchicine, Prednisone, and Cyclosporine. Monoclonal gammopathy has been ruled out based on lab work, as well as lupus and other autoimmune diseases. The clinic note states that the patient has failed fexofenadine, 360 milligrams (mg) twice-daily as well as montelukast (Singulair). The clinic notes also note that four times the normal dose of loratadine was also tried and failed. Xolair is being requested and is under review for medical necessity.

The health plan's determination is overturned. Xolair is medically necessary for this patient. The patient has tried and failed both four times the dose of both fexofenadine and loratadine, and also montelukast and multiple immunosuppressive/immunomodulatory medications. The current literature supports the conclusion that all reasonable first- and second-line treatments have been exhausted, and that Xolair is now medically necessary for the treatment of this patient's condition. After failure of oral antihistamines, immunomodulatory/suppressive medications, and montelukast, and after autoimmune diseases (such as lupus) have been ruled out, Xolair is now medically necessary for this patient's treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Primary hyperparathyroidism; multinodular goiter
Treatment: Inpatient hospital admission
Summary:  The inpatient hospital admission was not medically necessary.
Acute inpatient hospitalization was not medically necessary for this patient for the dates of service under review.  The medical records support that this patient could have been reasonably and safely monitored with an observational status (rather than acute inpatient admission).
This patient presented with the diagnosis of hyperparathyroidism and a multinodular goiter.  She underwent total thyroidectomy, parathyroidectomy (right inferior, right superior, portion of left inferior), right central neck dissection, cervical thymectomy with intraoperative RLN and iPTH monitoring.  
While there is risk for post-operative hypocalcemia following parathyroidectomy, this risk is minimized by the identification of each parathyroid gland that was performed in this case.  Also, the nadir for post-surgical calcium is not typically seen until 48 hours.  Intraoperative PTH monitoring confirmed 95% reduction in serum PTH with resection of the right inferior gland.  The progress notes do not describe any clinical manifestations of hypocalcemia.  Monitoring for hypocalcemia and post-surgical sero-hematoma was appropriate in this case, however, this could have reasonably and safely been provided without inpatient admission.  The operative report describes a successful and uncomplicated procedure.  There was no clinical evidence for neck swelling, post-operative bleeding or recurrent laryngeal nerve injury.  The post-surgical calcium value was 11.3 and intact PTH was 2.7.  This patient's clinical needs could have been appropriately satisfied with an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient has a past medical history significant for hypertension, peptic ulcer disease, and asthma, and presented to the emergency department on with chief complaint of chest pain and shortness of breath.  The patient reported two episodes of chest pain, which was associated with radiation to the left upper back and associated with eating. 

On presentation to the emergency department, the patient was noted to be afebrile with blood pressure 146/60, heart rate (HR) 69, and maintaining an oxygen saturation of greater than (>) 90% on room air and exam otherwise noted to be within normal limits.  Labs showed complete blood count (CBC), basic metabolic panel (BMP), troponin and D-dimer within normal limits. Electrocardiogram (EKG) revealed normal sinus rhythm with non-specific T wave changes.  Chest x-ray showed no acute process.  The patient was subsequently admitted to the hospital.  After admission, the patient was subsequently noted to be in atrial fibrillation with rapid ventricular response with rates up to the 140s.  The patient was started on metoprolol oral which effectively controlled the rate as well as anticoagulation.  Echocardiogram was performed which revealed no obvious embolism or valvular abnormality.  The patient was subsequently discharged. The health plan's determination is upheld.

Inpatient stay was not medically necessary. This patient presented with atypical chest pain and shortness of breath and was ultimately diagnosed with new atrial fibrillation that was easily controlled with low dose oral metoprolol. The patient did not have active ischemia or other cardiopulmonary process requiring inpatient treatment that was aggravating the atrial fibrillation. Rate was able to be easily controlled by low dose oral medications and the patient did not require active titration of intravenous (IV) drips or multiple oral medications to achieve adequate rate control. Acute inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vascular dementia
Treatment: Increase in personal care worker hours to six hours, five days 
The increase in personal care worker hours to six hours, five days is not medically necessary.

The patient is a male with documented history of vascular dementia with mental status exam score of 18.  His associated medical conditions include hypertension, which is controlled, and diabetes, which is controlled. The patient is noted to live alone, with a family member who visits once a week. The patient requires assistance with adult daily living tasks.  

Based upon the attached medical records and documents, the skilled care needs of this patient can be met with the current level of personal care aid assigned at five days per week, five hours per day.  No documented skilled care needs were provided by the family or treating physicians.  Instead, treating physicians and family document a need for a non-skilled sitter for safety.  

Therefore, given the above, the Increase in personal care worker hours to six hours, five days is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This patient presented with 3 day history of croupy cough, congestion, and two day history of fever. The Mother reports that the patient's cough worsened on the day prior to admission and overnight, the patient had been having fevers with axillary temp TMax 100.1F. The patient was admitted to the pediatric floor with stable respiratory status on room air. Respiratory status was monitored, breathing comfortably with oxygen saturations ranging from 96 to 100%. Fever curves were monitored and patient remained afebrile through the admission course. 

The health plan's determination is overturned. The inpatient stay was medically necessary. Based on the literature, the patient met multiple clinical criteria that are strong predictors of clinical deterioration and also possible need for major intervention. The infant exhibited increased work of breathing with accessory muscle use, hypoxia with an oxygen requirement and age of less than 12 months. Based on these clinical findings at presentation, inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

The patient is a smoker with a history of chronic obstructive pulmonary disease (COPD) who was discharged from an observation stay 2 weeks before because of a COPD exacerbation. The patient presented to the emergency room with 2 days of worsening symptoms-cough and shortness of breath. In the emergency room he was tachycardic with a pulse of 113 and respiratory rate of 20. Lungs show diffuse wheezes.

The health plan's determination is overturned. The inpatient stay was medically necessary. The patient had objective deterioration in room air oxygen saturation. This patient had an unresolved COPD exacerbation from 2 weeks before, and now had secondary worsening. He had an infiltrate on CT scan, and worsening with aggressive treatment. A lower level of care would have been put at high risk of morbidity and mortality.
Appeal type: Medical necessity
Decision: Upheld

Diagnoses:  type 2 diabetes mellitus with hypoglycemia without coma, altered mental status, unspecified and past medical history of liver cirrhosis, insulin-dependent diabetes mellitus, hypertension, hyperlipidemia, and right ankle open reduction with internal fixation (ORIF).

Treatment: Inpatient admission, diagnostic evaluation and medication management..

The insurer denied inpatient admission.  That denial was upheld.

The patient was transferred via Emergency Medical Services (EMS) to the Emergency Room on at 0557 with complaints of the patient not making any sense when she was talking.  She was making strange movements and did not recognize her husband.  The patient had recently been discharged from the hospital with a diagnosis of hyperkalemia and anemia.  Per the husband, the patient was found to be disoriented.  The patient's fasting blood sugar was found to be 40 and she was treated with 2 ampules of D5W.  Additional diagnostic testing was ordered.  After 2 ampules of D5W, the patient became alert x2 and was able to speak.  The Emergency Room physician determined she would require admission as her appetite was not back to normal and she would likely become hypoglycemic again if she returned home.  The patient was seen by physical therapy during her hospital stay due to deconditioning, and it was recommended that she ambulate with a cane.  She and her husband were educated about discontinuing the insulin due to lack of appetite.

In the clinical records there was documentation that the patient presented with altered mental status.  However, after 2 ampules of D5W, the patient became alert and oriented x 2 and had a glucose level of 350 at 0712.  The patient's altered mental status was not recurrent or persistent, and there were no significant clinical signs or symptoms that did not resolve or that would necessitate prolonged monitoring for recurrent hypoglycemia.  The inpatient admission level of care was not medically necessary for this patient. The patient could have been treated at an observation level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who was brought to emergency department (ED) by ambulance  with complaints of flank pain. Associated symptoms included nausea. A computed tomography (CT) scan-showed a right sided ureterovesical junction (UVJ) stone with hydroureteronephrosis. He was afebrile and hemodynamically stable on presentation. His white blood cell count (WBC) and creatinine were normal. An examination revealed costovertebral angle tenderness.  The health plan's determination of medical necessity is upheld.  This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control.
Appeal type: Medical necessity
Decision: Upheld

This patient has a history of Lupus who presented to the Emergency Department with a 4 week history of increased shortness of breath and lower extremity rash and edema. Upon presentation to the emergency room, the patient's vitals were noted to be stable: the patient was not tachycardiac, tachypneic, febrile, or hypotensive. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient could have been cared for at a lower level of care. She did not show any signs of respiratory distress, she was not hypoxic or tachypneic. Laboratory work, radiology, and echo did not reveal any new findings or demonstrate any significant abnormalities that would warrant inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient has a past medical history significant for hypertension and tobacco abuse who presented to the emergency department with complaints of worsening shortness of breath and dyspnea on exertion, which started approximately two weeks before the day of admission. As a result of the treatment, patient's symptoms improved rapidly, and the patient was discharged from the hospital the next day after the day of admission.

The health plan's determination of medical necessity is upheld. A careful review of the patient's records demonstrated that he had no clinical features requiring admission at the inpatient level of care. Overall, the patient had relatively mild COPD exacerbation that was not associated with acute respiratory failure. There was no evidence of underlying pneumonia or CHF. Therefore, the patient did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: BPH
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
Care after an uncomplicated TURP can be provided at a lower level of care.  Because there were no signs of complications, infection, excessive bleeding, or instability an acute inpatient level of care was not necessary.  The care of his comorbid conditions was routine.  A lower level of care was appropriate, even with use of CBI.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious disease
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children. There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of five years. Most cases are caused by viruses, are self-limited, and require supportive treatment. According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Output (vomiting, diarrhea) limits the success of oral rehydration, prompting use of anti-emetic medications.
 
According to current guidelines for evaluation and management of acute diarrheal illness, people with fevers or bloody diarrhea, as well as severe cramping or signs of sepsis, should undergo diagnostic studies to determine if antimicrobial agents are appropriate. Additional testing such as blood cultures may also be indicated. 

This patient presented to the ED at approximately one year of age with frequent diarrhea stools while on a course of antibiotic therapy for presumed urinary tract infection. The stools were concerning for the presence of blood based on the family's description. In the ED, he passed six stools, with two negative tests for occult blood. However, testing for C. diff was positive. With concern for dehydration and colitis, the baby was admitted and placed on treatment (despite ID recommendation to hold antibiotics). While it was reasonable to observe the baby and his ability to drink to keep up with diarrhea losses, he was overall hemodynamically stable and did not require acute inpatient management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes Mellitus
Treatment: Inpatient Hospital

Summary:  This patient with a past medical history of diabetes mellitus, obesity and asthma was seen in the Emergency Department (ED) with complaints of right ear pain for three days and nasal congestion with yellow mucus and scant blood for one day.  The patient had a recent sick contact one week prior to presentation.  The patient was not taking any diabetes medication due to lack of insurance.  The patient stated that she had been monitoring her blood sugar through diet and exercise.  The patient had not checked her blood sugar since running out of insulin.  The patient noted that she has had diabetic ketoacidosis in the past when first diagnosed.  The patient noted an intentional 134 pound weight loss in one year.  The patient's blood sugar in the ED was high.  The patient was given intravenous (IV) fluids and insulin and was admitted for further evaluation and management.  The patient was started on Lantus and Lispro.  The patient's blood sugars improved, and the patient was discharged with 70/30 insulin.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

The medical literature indicates that inpatient admission is indicated for patients with diabetes if there is evidence of diabetic ketoacidosis that requires inpatient management as indicated by hyperglycemia with a plasma glucose greater than 200 mg/DL, ketonuria or ketonemia with a serum beta hydroxybutyrate greater than 3, acidosis with an arterial or venous pH less than 7.3. Inpatient care may also be indicated for patients with hyperglycemic hyperosmolar state if there is evidence of plasma glucose greater than 600 mg/DL with serum osmolality greater than 320 and neurologic dysfunction. The documentation indicated that the patient was seen for ear pain. The patient was noted to have glucose greater than 530 and an HbA1c of 16.9. The patient's venous pH was 7.30. However, there was no indication that the patient had ketonuria or ketonemia with a serum beta hydroxybutyrate greater than 3. The patient's arterial or venous pH was not less than 7.30. There was no indication the patient had a serum osmolality greater than 320 and there was no evidence of neurologic dysfunction. Therefore, the patient's condition was appropriate for level of observational care rather than inpatient level care. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: High blood pressure and blurry vision
Treatment: Inpatient admission
Inpatient level of care was not medically necessary.
A hypertensive emergency is present when severe hypertension is associated with acute end-organ damage. Examples include hypertensive encephalopathy, acute pulmonary edema, aortic dissection, and rebound after abrupt withdrawal of antihypertensive medications. This presentation does not satisfy the conditions needed for diagnosis. There was no papilledema, renal failure, cerebral vascular accident (CVA), altered mental status, unstable angina. CT of the head was negative. EKG was normal, echocardiogram was normal, enzymes were negative, and renal function was normal. Exam was normal with no papilledema, no heart gallop, no heart failure or abnormal mental status. Progress notes stated patient was stable.
Determination of level of care depends on actual care given and the environment need to provide that care and treatment. In this case, the medications given, and the tests performed were appropriate and safe for a lower level of care.
The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

This patient presented with a four month history of chest pain on exertion.  Angina description was atypical in character.  No high risk features were noted on ECG at presentation, and serum troponin testing was negative.  Physical examination was unremarkable. These findings are not consistent with an acute coronary syndrome (ACS).  

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG as well as negative cardiac enzymes was performed by Poldevaart et al. (Reference 1).  Using the HEART (History, EKG, Age, Risk factors, initial Troponin) score risk stratification schema, this patient would have a low risk of future myocardial infarction or death within one year. 

Other investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care. (References 2&3)  They found no significant difference in outcome at 30 days between the two groups.  

Fernando Bellolio et al. noted that patients presenting with chest pain that were managed in an observation unit had similar 30 day myocardial infarction rates as those admitted to the hospital. (Reference 3)  

Admission to the hospital to treat an acute cardiac event was not medically necessary.  In conclusion, this patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cough, Fever, Chest Pain
Treatment: Inpatient Admission
The inpatient admission was medically necessary.

This patient presented with hypertensive emergency, fever, cough and chest pain.  The patient subsequently developed atrial fibrillation with rapid ventricular rates, as well as pulmonary edema. Hypertensive emergency is defined as BP > (great than) 180/120 with target organ damage (Reference 1).  In this patient, BNP (brain natriuretic peptide) was elevated consistent with left ventricular dysfunction and target organ damage. Given this patient's previous history of aortic dissection, admission to the hospital for aggressive blood pressure management was necessary. In fact, American Heart Association guidelines recommend admission to the ICU for management of hypertensive emergencies (Reference 1).  

Additional reasons for hospital admission included treatment of rapidly conducted atrial fibrillation and influenza A infection. Patients presenting with atrial arrhythmia with rapid ventricular rates require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. 

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 2).  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. 

In conclusion, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Clogged feeding tube
 
Treatment: Inpatient admission, interventional procedure

The insurer denied the admission. The denial was upheld.

This case involves patient who presented to the Emergency Department with a clogged percutaneous endoscopic gastrostomy (PEG) tube. The patient was admitted for PEG tube malfunction and had an Interventional Radiology (IR) evaluation.  The patient underwent a removal of the blockage in IR.  The patient was then discharged.

The records failed to support that the patient was unstable or had findings to support the need for inpatient admission. The patient could have undergone the procedure as an outpatient or been placed on observation status.