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

Diagnosis: Gastroenteritis

Treatment: Inpatient Admission

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

This is a young female patient who presented to the hospital by her mother with complaints of vomiting, fever, and loose stools for several days. A physical exam was performed that revealed the patient to be awake and alert, mucus membranes were moist, and her abdomen was soft and non-distended; the patient's diaper appeared to be wet.  Laboratory work up was performed that showed sodium 144, potassium 4, blood urea nitrogen (BUN) 15, creatinine <0.2, chloride 108, bicarbonate 17 and glucose 109. Urinalysis was notable for specific gravity > 1.030, pH 6 and dip + for small ketones, 1+ protein and blood. Intravenous (IV) fluid blouses were given with continued maintenance fluids. It was reported that the patient had one episode of vomiting and two episodes of loose stool; IV Zofran was administered with a positive response. The patient was able to tolerate oral feeding with no further episodes of vomiting and loose stools. After a period of medical stability the patient was discharged home. 

This child appears to have acute viral gastroenteritis with self-limited vomiting and minimal dehydration that responded to modest intravenous repletion. Her physical exam, laboratories and vitals were for the most part unremarkable (heart rate for age elevated during fever only). In accordance with a review of the approach to nausea and vomiting in children from UptoDate the reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the Emergency Department, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge, poorly controlled pain with an oral pain medication regimen, concerning physical exam findings for a surgical process or findings consistent with significant blood loss or bowel obstruction. She did not meet any of these criteria to merit the inpatient setting.
 
The documentation of this child's wet diapers, moist mucus membranes, normal activity and crying with tears would support mild hydration at best. After bolus fluids in the Emergency Department her small ketones would have cleared and her post-tussive vomiting resolved with a single dose of Zofran after presentation.  She tolerated oral hydration in the Emergency Department and throughout her admission. 

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

Based on the above, the medical necessity for the inpatient admission is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea, abdominal pain, hyperglycemia
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.
The Inpatient admission was not medically necessary.
This patient is a female with diabetes, bipolar disorder, depression, congestive heart failure (CHF), and history of myocardial infarction. She presented with nausea, abdominal pain, and hyperglycemia. 

The patient's glucose was 1066 mg/dL, potassium 5.7, lactate 2.2 and 4.1, CO2 (carbon dioxide) 23, creatinine 1.2, pH 7.41. Her temperature was 98.6, heart rate 98, BP (blood pressure) 162/99. She was treated with ceftriaxone, normal saline, insulin drop, and sodium bicarbonate. Inpatient admission is under review.  

This patient presented with hyperglycemia and dehydration in the setting of missed insulin. She was hypertensive on admission but hemodynamically stable. Her CO2 and pH levels were normal, which indicates that the patient did not have diabetic ketoacidosis. She did not have altered mental status to support a diagnosis of hyperglycemic hyperosmolar syndrome. She had normal renal function. She has chronic heart failure but without evidence of an acute exacerbation. She had marked hyperglycemia that rapidly improved with treatment. Therefore, no, the proposed inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 Diabetes Mellitus

Treatment: Continuous Glucose Monitor and Supplies, K0553, 1 month supply

The insurer denied the continuous glucose monitor and supplies, K0553, 1 month supply. The denial was reversed.

This is a male patient with a history of hypertension, type 2 diabetes mellitus, and hyperlipidemia. The patient's hemoglobin A1c level was 9.3. It was reported that the patient's diabetes is uncontrolled on his current medication regimen. A request for glucose monitor and supplies was made. 

Based on the review of the medical records provided, the patient's hemoglobin A1c is elevated and his diabetes is uncontrolled on his insulin regimen. The patient was at risk for complications associated with diabetes, such as limb amputation and sepsis. Based on this review of the literature on continuous glucose monitoring and its benefits in improving the glycemic index, the one month supply of continuous glucose monitor and supplies, K0553 is considered medically necessary to treat this patient's medical condition.     

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.                

The carrier's denial of coverage for the one month supply of continuous glucose monitor and supplies, K0553 is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gunshot Wound
 
Treatment: Inpatient Admission

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

This is a young female who was transferred from another medical facility after she experienced a gunshot wound that entered and exited her thoracic spine. She was admitted to the Pediatric Intensive Care Unit (PICU) for further treatment. Upon admission she was medically stable without neurological deficits. A computed tomography (CT) of the chest was performed that revealed a fib fracture and an incidental finding of a pneumatocele, and was negative for a pneumothorax and a hemothorax. She did sustain a rib fracture from the gunshot wound. She remained stable, eating by mouth, well saturated on room air, and did not require additional respiratory or hemodynamic support. She is described as breathing comfortably, alert and oriented and neurologically intact. She experienced no respiratory distress or hemodynamic instability and was discharged home.

According to Naranje, et al. (2016), it is noted that "This large retrospective study highlights the significant morbidity of fractures caused by gunshots. Although the overall infection rate was low and most of these fractures were successfully treated nonoperatively, many of the patients required an additional operative procedure and nearly half had additional nonorthopaedic injuries." 

According to Strumwasser, et al. (2016), it is noted that "Thoracic CT has a negative predictive value of 99% in triaging hemodynamically normal patients with penetrating chest trauma. Screening thoracic CT successfully excludes surgery in patients with non-significant radiologic findings."

Finally per Abghari, et al. (2015), "The average length of hospital stay in days varied according to the type of injury sustained by patients. Forty-three out of 97 (44.3%) patients with soft tissue injuries only were discharged on the day of admission, most of which underwent non-operative treatment. The average length of hospital stay for soft tissue injuries without vascular damage was 1.2 days (range 010). Patients who sustained bony injuries along with soft tissue injuries average length of hospital stay was 7.1 days (range 088). The average length of stay for patients who sustained vascular injuries along with other soft tissue injuries was 11.7 days (range 024). Those injuries that included a combination of vascular, bony and soft tissue injuries stayed for an average 17.0 days (range 035, 0 = died same day of admission). Patients who sustained multiple organ injuries had hospital stays at an average of 13.5 days (range 233)."                                                         

The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

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

Diagnosis: Colitis
Issue under review: Continued inpatient admission at OON facility

Determination:
The patient's condition was not such that the continued inpatient admission at the out-of-network hospital was medically necessary.

The patient is an adult female. She has h/o (history of) hypertension, obesity, hypothyroidism, and pituitary tumor s/p (status post) resection. She presented to the ED with abdominal pain of two weeks duration. The abdominal pain was associated with nausea and vomiting. She was admitted to an outside hospital prior to this admission, and evaluated and treated for gall stones and kidney stone. She was discharged home from that hospital and recommended laparoscopic cholecystectomy in the near future. She then presented to her PCP (primary care provider) with worsening right-sided abdominal pain, nausea and vomiting, constipation from opioid use, and chest pain. 

In the ED, the patient was treated with IV fluids, Pepcid, Maalox, IV Morphine, IV Zofran, and IV normal saline. Her labs include CBC (complete blood count), CMP (comprehensive metabolic panel) and lactate. The CBC was normal. The CMP revealed mildly elevated liver function tests. The lactate was mildly elevated, which normalized after IV fluids. The CT scan of the abdomen revealed mild right sided colitis, right ovarian cyst, mild splenomegaly, and normal pancreas.

The patient was admitted to the hospital and continued on IV fluids, IV Morphine PRN (as needed) for pain, IV Zofran PRN for nausea and vomiting, IV Protonix, IV Levaquin and Flagyl, and lactobacillus. She was started on clear liquid diet, which she tolerated fairly well. Her abdominal pain improved, and her diet was progressed to low fiber diet on the first date of service under review, which she tolerated well. The plan was to transfer her to in-network facility. She was continued on antibiotics, lactobacillus, Zofran, Protonix as before, and ultimately discharged home on antibiotics and lactobacillus, and advised to undergo colonoscopy as an outpatient basis.

The patient was doing well on the first date of service under review and was tolerating low residue diet. Her abdominal pain, nausea and vomiting had resolved. She was afebrile and hemodynamically stable, and did not require any surgical or endoscopic intervention. Therefore, she could have been safely transferred to an in-network facility for further management of her condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvic mass; hydronephrosis
 
Treatment: Inpatient Admission

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

This is a female patient with a medical history of hypertension, diabetes and kidney and pancreatic transplant. She had recently been hospitalized for complaints of lower extremity edema, dyspnea and abdominal distension. She was discharged with instructions to have MRI as an outpatient however she continued to have complaints of shortness of breath and abdominal distension which caused her to present back to the Emergency Department (ED). Upon physical exam it was noted that her abdomen was distended and her lower extremities were swollen; her symptoms were likely related to her pelvic mass. She also complained of seeing spot, her blood sugar was checked with a result of 66; she drank 200 mls of orange juice. She had several consulted upon readmission with several diagnostic tests. A computer tomography (CT) scan of the chest showed mild septal thickening with a nodular thyroid.  A chest x-ray did show pulmonary edema and questionable trace pleural effusion.  A pelvic ultrasound was also ordered showing a mass in the middle of the pelvis containing cystic and solid components with an increase in size. She was treated with intravenous (IV) Lasix. Her condition improved and it was recommended that she follow up gastroenterology and treatment for her hypoglycemia event. 

Early readmissions have been correlated to patients with multiple co-morbidities, living alone, and pending testing results at discharge.  Her initial discharge required an outpatient evaluation by MRI for a pelvic mass noted on imaging in mid-2019.  The prevailing reason for her admission appears to be a possible opportunistic infection due to an immunocompromised state caused by use of Tacrolimus/ Mycophenolate/ Prednisone.  Presumably, a return visit to the Emergency Department (ED) due to symptoms of dyspnea after a recent hospital stay would include hospital acquired pathogens as a nidus for the chest imaging changes.  The chosen treatment of Rocephin/Azithromycin suggests the Infectious Diseases (ID) consultant and treating team did not believe there were hospital pathogens as the source of her concerns.  This is supported by normal vital signs, saturation level, and no systemic inflammatory response syndrome (SIRS) on presentation.  Further, the procalcitonin level measuring 0.3 ng/dl can be explained by her chronic inflammation state or her end stage renal status.  

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

Diagnosis: Back Pain
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

The patient is a woman who complained of low back radiating to her right LE (lower extremity), along with right LE paresthesias. A lumbar MRI (magnetic resonance image) demonstrated severe canal stenosis at L4-5. The patient underwent a L4-5 laminectomy.  No complications were reported.  

The patient was given perioperative antibiotics, IV (intravenous) fluid, and insulin coverage, and was observed in the hospital overnight and discharged to home the next day after a PT (physical therapy) evaluation.

The patient underwent L4-5 laminectomy to treat her severe canal stenosis at this level.  No complications were reported.  Observation in the hospital overnight following the procedure is routine and justified.  Per the medical records provided, the patient could have been managed at an observation level of care as there were no complications that warranted inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Myocardial Infarction
 
Treatment: Inpatient Admission

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

This is a male patient with a medical history of paroxysmal atrial fibrillation who presented to the emergency department with complaints of fever, pain, weakness, and body aches. The patient was consulted by Cardiology. He had an electrocardiogram (EKG) the showed atrial fibrillation with rapid ventricular response. A computed tomography was done that was negative for a pulmonary embolism. He was started on Metoprolol. He was discharged home with instruction to follow up with outpatient cardiology. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Inpatient admission was not medically necessary for this patient. In the absence of evidence of myocardial ischemia, hypoxemia, hemodynamic instability, or other end-organ dysfunction, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing. Inpatient admission criteria were not met. Although the patient had new onset symptoms, medical policy criteria were not met for any other additional extenuating circumstances. 

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

Diagnosis: Chest Pain 
 
Treatment: Inpatient Admission

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

This is a female patient with a medical history of hypertension, hyperlipidemia, asthma, aortic valve replacement, anxiety and migraines. She presented to the emergency department (ED) with complaints of chest pain and shortness of breath. Prior to coming to the ED she reported taking Clonazepam, aspirin and two puffs of albuterol inhaler. The patient was consulted by Cardiology. She was monitored on telemetry. An electrocardiogram was done with no acute findings for a cardiac event. She had extensive laboratory work up including serial cardiac enzymes which were negative and a D dimer test which was elevated. A computer tomography (CT) of the chest was performed which was negative for a pulmonary embolism. She received respiratory nebulization treatments and steroids with noted improvement in her symptoms. It was determined that her symptoms were as a result of mild asthma exacerbation. She was discharged on an eight day course of oral steroids. 

High-sensitivity cardiac troponin T (hs-cTnT) have been introduced as a highly sensitive and early biomarker of myocardial damage (1). In two prospective cohorts of patients admitted to the hospital for chest pain, undetectable hs-cTnT was found to have a very high negative predictive value for myocardial infarction [MI] (2, 3). A 2014 study from Sweden evaluated the significance of undetectable troponin levels and EKGs which did not show signs of ischemia in patients presenting to the emergency department with chest pain. (4) All patients who sought medical attention for chest pain and had at least 1 hs-cTnT analyzed during 2 years at the Karolinska University Hospital, Stockholm, Sweden, were included. They calculated the negative predictive values of an undetectable hs-cTnT and ECG without ischemia for MI and death within 30 days. The negative predictive value for MI within 30 days in patients with undetectable hs-cTnT and no ischemic ECG changes was 99.8% (95% confidence interval [CI]: 99.7 to 99.9). The negative predictive value for death was 100% (95% CI: 99.9 to 100). They conclude that all patients with chest pain who have an initial hs-cTnT level of <5 ng/l and no signs of ischemia on an ECG have a minimal risk of MI or death within 30 days, and can be safely discharged directly from the ED.

Multiple observation protocols have been developed which have been shown to be safe and deliver effective care. Recognizing the value of an Observation Unit, studies report that over one third of hospitals now have implemented an ED observation unit. 

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: Overturned

Diagnosis: Substance Abuse
 
Treatment: Inpatient Substance Rehabilitation 

The insurer denied the Inpatient Substance Rehabilitation. The denial was reversed.   

This is a male patient with a history of alcohol and crack/cocaine use for almost four decades. He has had multiple inpatient substance detoxifications and rehabilitation and remains unable to abstain due to the lack of coping skills. He was transferred to inpatient substance rehabilitation several days after admission upon the availability of a bed.

According to the LOCADTR he met criteria for inpatient substance rehabilitation treatment as he continued to use serious substances including cocaine/crack and large amounts of alcohol daily despite multiple past inpatient substance detoxification and rehabilitation treatments as he continued to relapse and was unable to maintain abstinence. This was evidence that he required a sober and supervised structured therapeutic inpatient substance rehabilitation treatment setting to give him the best chance of working on improving coping skills, better identify relapse triggers, and improve relapse prevention skills. It was not likely that he could safely and effectively be treated in a less restrictive setting other than an inpatient substance rehabilitation treatment as he had past inpatient substance rehabilitation treatments and continued to relapse so a less restrictive level of care was not likely to be effective. He required inpatient rehabilitation treatment as a step down from inpatient substance detoxification. He likely would have relapsed if not in this intensive and structured therapeutic inpatient substance rehabilitation treatment. He lacked coping skills, needed to better identify relapse triggers needed to work on relapse prevention strategies, and he was unable to stop substance and alcohol use without being in this setting. Without this structured and supervised therapeutic inpatient substance rehabilitation treatment, he likely would have relapsed quickly again. 

As a result, the determination is to reverse the previous decision and approve coverage for inpatient substance rehabilitation treatment, when a bed became available he was transferred for further inpatient substance rehabilitation treatment. It did not appear that the health care plan acted reasonably or in the best interests of the individual. 

Based on the above, the medical necessity for the inpatient rehabilitation is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

The patient is an adult female with abdominal pain and neck pain. She had abnormal CT-neck as outpatient. The patient was sent to the emergency room for further work up. 

The CT-abdominal and pelvis in the emergency room showed right middle lobe infiltrate. The patient was admitted for IV antibiotics for pneumonia and weakness. The patient was discharged home within 24 hours of the admission.

The patient was hemodynamically stable. The patient's blood work was with in normal range. The patient was tolerating oral diet. The patient received IV antibiotics and IV fluids. The acute in hospital level of care was not medically necessary. The patient could have been safely and effectively treated as an observation level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p accident
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is a male child who was taken to the emergency department (ED) via EMS after being hit by the front of a slow-moving car while he was on his scooter. There was no loss of consciousness (it was witnessed by his brother) and EMS was contacted immediately. He was crying uncontrollably but had no complaints of pain. He fell and hit the right side of his face on the ground. 

This young male child was hit by a slow-moving car while riding a scooter, fell to the ground without loss of consciousness, and hit his head causing an abrasion at his left eyebrow. He was evaluated in the ED with multiple modalities and no injuries were revealed. However, because of his young age and the potential for occult injury, he was admitted to the pediatric ward for overnight observation. 

While it was not unreasonable to monitor him overnight, he was overall hemodynamically stable with no overt evidence of injury. He did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.