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

Diagnosis:  Neck and arm pain
Treatment:  Inpatient admission

The Inpatient admission was not medically necessary.  

The patient is a female patient with several year history of neck and arm pain.  MRI revealed cervical disk degeneration, disc herniations and foraminal stenosis.  Conservative management, including activity modification and NSAIDs (nonsteroidal anti-inflammatory drugs), had failed to provide relief.  

The patient was admitted, and she underwent anterior cervical discectomy and fusion C5-6 and C6-7.  The patient transferred independently and ambulated with PT (physical therapy).  She was safe with all functional mobility.  Progress note documented pain controlled and stable vital signs.  She was given Robaxin and oxycodone for pain and required Reglan IV for nausea.  Progress note noted that her nausea was improving.  The patient was discharged.

The patient was stable, medically cleared by physical therapy, and on an oral pain medication regimen.  There was no medical reason for the patient to stay an extra night.  The patient could have been treated at a lower level of care.

Anterior cervical fusion can typically be performed as an outpatient procedure.  This patient was medically stable.  According to the records, there was no evident indication for a prolonged inpatient stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Central Nervous System/Neuromuscular Disorder - Seizures
Treatment:  Inpatient Hospital

The patient is a male, with history of febrile seizures as a toddler, who presented to the emergency department (ED) with a complaint of shaking.  These episodes of brief jerking had started the day of presentation, happening every couple minutes while awake.  They involved all 4 extremities.  There was no history of fever, illness, weakness, numbness or tingling, or trauma.
ED vitals were T 98.3F, heart rate (HR) 81, respiratory rate (RR) 19, blood pressure (BP) 108/74, and O2 saturation of 99% on room air.  Weight was 96 pounds.  Exam was unremarkable.  Labs showed white blood cell (WBC)10.4, hemoglobin (Hgb) 14, platelets (Plt) 206, electrolytes were normal.  Acetaminophen, salicylate, and thyroid levels were normal.  He was noted to have some very brief, jerking movements of the torso and extremities that were suppressible (patient could actively stop them from happening).  The patient was admitted to the inpatient unit with a diagnosis of myoclonic jerking.  He was seen in consultation by pediatric neurology, had electroencephalogram (EEG) and head magnetic resonance imaging (MRI), in addition to antistreptolysin (ASO) titer and erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP).  EEG was abnormal, suggestive of a structural lesion in the left hemisphere, though demonstrated no epileptiform activity.  ESR and ASO were mildly elevated but not thought to be pathologic.  Head MRI was normal.  Neurology diagnosed probable tic disorder, and the patient was discharged home with outpatient follow-up.

This patient presented to the ED with new onset of jerking movements that were able to be suppressed.  He did not have fevers or evidence of infection or systemic illness.  There was no history of trauma and no loss of consciousness with these events.  His vital signs were stable.  The differential diagnosis for this patient was myoclonic seizures versus tic disorder.

The requested inpatient hospitalization was not considered medically necessary for this patient.  There was no vital sign abnormality, no loss of conscious or uncontrollable jerking requiring medication or other treatment.  Based on the observations from the ED, this patient could have safely received the necessary tests in a lower setting of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The proposed inpatient admission was not medically necessary; inpatient level of care was neither indicated nor provided.

This is a female that presented with sharp chest pain. She had no history of / or risk factors for coronary artery disease (CAD). Work up included a normal chest x-ray (CXR), and a nuclear stress test that was negative for ischemia, Echocardiogram did not show wall motion abnormality. Enzymes were normal and electrocardiograms (EKGs) were normal. Work up did reveal a renal calculus which was treated. The patient was discharged to home.

The determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is required to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome. Exam and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. CXR was normal. Echocardiogram showed no wall motion abnormality.  Nuclear scan was negative for CAD. The physicians' treatment did not reflect any serious concern about the patient's cardiac condition.  Orders did not include medical therapy for acute coronary syndrome (ACS) such as intravenous (IV) heparin, dual anti-platelet inhibitors, high dose beta blockers or IV nitroglycerine (NTG).  

The patient was found to have a kidney stone which was treated. That treatment did not require a higher level of care.

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. Patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care.

There was no "complex" care that required inpatient level of care in this patient's care. This patient had no evidence of CAD. All tests showed absence of ischemia.  While there is always a potential for an adverse event, one did not happen and no actual treatment was added. All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.

Milliman criteria requirements were not fulfilled as there was never any evidence of ACS present.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male that presented to the hospital for elective left atrial catheter ablation for persistent atrial fibrillation.  Past medical history was significant for hypertension, remote cryoablation for atrial fibrillation and cavotricuspid isthmus ablation for atrial flutter.  

The patient underwent uncomplicated left atrial catheter mapping and ablation.  All pulmonary veins were noted to have electrical activity and requisite isolation.  The procedure was uncomplicated, and the patient was discharged the following day.

This patient presented to the hospital for an elective electrophysiologic (EP) study and ablation.  According to hospital records, the ablation was successfully performed without complication.  Observation following ablation was unremarkable and no post-operative issues were noted.  The patient was discharged home the following day.  In this case, there were no clinical reasons for hospital admission and the patient could safely be managed at a lower level of care. 

In two multicenter registry studies looking at healthcare utilization after EP study catheter ablation, more than 80% of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity. (1)  Another study demonstrated that patients undergoing atrial fibrillation ablation procedures could be safely discharged on the same day. (2) The current standard of care in an uncomplicated atrial fibrillation ablation is to manage patients at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of hypertension hyperlipidemia, presented to the emergency department with nausea, vomiting, and epigastric discomfort. Symptoms started 2 days prior to presentation, with reports of inability to keep food down and she had not had anything aside from water in 24 hours. The pain was described as constant, located in the epigastrium. There were no clear alleviating or exacerbating factors. The patient also experienced one episode of right arm pain, occurring 1 day prior to arrival as well.  The health plan's determination of medical necessity is upheld.The requested health service/treatment of inpatient hospitalization for the above date is not medically necessary for this patient. This is a nonspecific chest pain rule out presentation. The patient had EKG changes, which per the emergency department were chronic and unchanged from previous EKGs. The patient had negative cardiac enzymes and no evidence of ST elevation.
Appeal type: Medical necessity
Decision: Upheld

The patient has a past medical history significant for ulcerative colitis and past surgical history significant for ileoanal pouch who was seen for decreasing fecal latency. The progress note states the patient has minimal fecal incontinence with decreased fecal latency; symptoms have improved since starting cholestyramine. The use of the sacral nerve stimulator is under review.

The health plan's determination is upheld. The sacral nerve stimulator is not indicated. The Sacral Neurostimulator is not indicated as the degree chronic fecal incontinence (e.g. greater than 2 episodes per week x 6 months) and failure of conservative therapies (e.g. loperamide, cholestyramine) are not documented in the medical records provided.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes mellitus, CHF, CVA
Treatment: Personal Care Assistance, Level II 24 hours per day, seven days per week (split shift or live in).

This patient with a history of Diabetes Mellitus, Congestive Heart Failure, Cerebrovascular Accident with residual left sided weakness, poor visual acuity and gait ataxia.
Due to the severity of his multiple comorbid conditions, he requires assistance with the majority of his activities of daily living (ADLs). Although it is clear that this patient needs 24/7 assistance, his current needs actually require a higher level of care then what a Personal Care Aid/Home Health Aid can provide. Admission and long term residence in a skilled nursing facility is warranted, as the patient cannot be left alone. He requires safety supervision at all times. He is unable to self-direct his own care. He requires maximum assistance with transfers and requires two-person assistance. 

Furthermore, he requires total assistance with pouring and administering 15 medications up to four times a day. For these reasons, the proposed treatment of Personal Care Assistance, Level 11 24 hours per day, seven days per week (split shift or live in); for a total of 168 hours per week is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
 
Treatment: Admission for Inpatient Substance Rehabilitation Treatment

The insurer denied the coverage. The denial was reversed.

This male patient was admitted to inpatient substance rehabilitation treatment in mid-2018. He was reportedly using 1 bag of heroin per day and $25 of cannabis per day with last use on the day of admission. He was using heroin since age 25 and cannabis since age 16. He reportedly had family conflicts due to substance use, spent time with drug seeking behaviors, was unemployed, and unable to gain employment as a result. He reportedly could not maintain abstinence on his own and lacked insight into addiction. He reportedly had past inpatient substance detoxification treatment. He was homeless and was transferred to another inpatient substance rehabilitation treatment in mid-2018.

The insurer denied coverage for inpatient substance rehabilitation treatment, as not medically necessary treatment. They stated that he did not have dangerous withdrawal, medical or mental health issues requiring 24 hour treatment, and they recommended a less restrictive level of care then.

According to the LOCADTR he met criteria for substance residential treatment as he continued to use multiple substances despite treatment past inpatient substance treatment settings and he had positive toxicology for THC and opiates and lacked supports as he was homeless. The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. Residential facilities provide a safe and substance-free environment in which residents learn individual and group living skills for preventing relapse. In this case the patient was considered in need of 24 hour residential treatment as he was discharged to another inpatient substance rehabilitation treatment. The patient lacked insight into their addiction and needed better coping skills, identification of relapse triggers, was unable to maintain abstinence on his own without this 24 hour therapeutic setting, needed more insight into addiction, was homeless and lacked supports for treatment as an outpatient.
Appeal type: Experimental/Investigational
Decision: Overturned

Cardiac
Surgical services

The patient has symptomatic atrial fibrillation status/post ablation twice, s/p AV nodal ablation and pacer implementation. Echocardiogram shows an ejection fraction (EF) 50-55%, mild mitral insufficiency only. Nuclear stress test shows no reversible ischemia and normal LV size and function. The patient has been on Tikosyn and has been in sinus rhythm briefly before reverting into atrial fibrillation. The patient is on coumadin.
Patient reports headaches, fatigue and dyspnea on exertion with atrial fibrillation. The health plan's determination is uphold in whole. In this patient's case, the proposed service of the Hybrid Procedure is not likely to be more beneficial than standard treatment for the insured's condition. The proposed procedure - the hybrid ablation is likely to be as effective as additional therapy with an increased complication rate. The proposed procedure - the hybrid ablation has been shown to have more complications in pooled studies with higher complication rates. In this patient's case, the symptoms and workup suggest adequate cardiac function despite atrial fibrillation.  From the STS guidelines, no inference specific to the CONVERGENT procedure can be made for this patient or any other.  The efficacy of the convergent atrial fibrillation procedure is relatively satisfactory. However, the overall complication incidence is relatively high, and the procedural mortality rate is unacceptable.
Appeal type: Experimental/Investigational
Decision: Overturned

Cardiac
Surgical services

The patient has known atrial fibrillation. Patient has had 2 previous percutaneous ablative procedures  with recurrence of atrial fibrillation. The patient  then had an AV node ablation and permanent pacemaker placement. Paitent developed recurrent atrial fibrillation which caused severe fatigue. Patient was converted with Tikosyn but continued to have episodes. In fact,  pacemaker interrogation showed AF approximately 85% of the time. A nuclear study and echocardiography were essentially unremarkable. Patient was referred to a cardiac surgeon for consideration of a surgical procedure (MAZE) to treat the atrial fibrillation as well as a third ablative procedure percutaneously. The patient was on carvedilol and coumadin. The patient had a transesophageal echocardiogram which showed no thrombi in the left and right atrial appendages. The health plan's determination is overturned in whole. The proposed Maze procedure is likely to be more beneficial than any standard treatment for the patient's life threatening condition. This patient falls into a subgroup of patients with atrial fibrillation who become very symptomatic with development of atrial fibrillation. Patient has been treated with two previous endovascular ablations, AV node ablation, and permanent pacer. Despite that, when the patient develops AF,  becomes very symptomatic. As a result, the providers, both surgeon and electrophysiologic (EP) physician, feel that a combined surgical and endovascular approach will be most helpful for this particular patient. There is some evidence for this approach in the medical literature, but it is currently incomplete. However, in an individual patient a specific plan is required. By guidelines, surgical intervention alone is classified as IIB , i.e. it may be helpful in an individual patient. Such is the case here. As such, it is considered that surgical intervention is medically necessary. The Heart Team feels that repeat endovascular ablation is also worthwhile, the so-called hybrid approach. There are data in the medical literature about the efficacy of this approach. Again, the value of this approach is uncertain, with some data supporting its efficacy. Its use must be individualized. It is reasonable and considered medically necessary in this highly symptomatic patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intractable abdominal pain

Treatment: Inpatient Admission 

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

This is a male patient who presented to the Emergency Department (ED) with complaints of nausea and vomiting and new onset abdominal pain that began after he bent over. He had a history of nicotine dependency and a recent colonic resection secondary to a diverticulitis several weeks prior to his ED presentation. A series of diagnostic testing was performed, all with normal results. He was discharged home. While in his car he began to experience vomiting, he returned to the ED. He complained of worsening right sided abdominal pain; rating it 9/10 in severity. His blood pressure at that time was 155/113 and his heart rate was 95. Gastroenterology consulted on the patient. He received intravenous (IV) fluids, morphine, Reglan, and Benadryl. He reported pain relief after three doses of morphine administration. The patient was admitted with a diagnosis of intractable abdominal pain.  On admission, the patient had tenderness to palpation in all 4 quadrants of the abdomen.  He was medically stabilized and discharged home with instructions to follow up with gastroenterology.

This patient had no significant laboratory abnormality, no peritoneal signs or acute abdomen, no sign of sepsis, no end organ damage or abnormality that warranted inpatient status.  The patient could have received intravenous fluids and intravenous pain medications in observation status.

Based on the review of the literature, patients that need hospitalization are those with the following signs and symptoms: volume depletion/dehydration, altered mental status, significant rectal bleeding, prolonged symptoms (more than a week), severe abdominal pain, comorbidities such as diabetes (immunocompromised status),  recent hospitalization or antibiotics, pregnancy, or weight loss.  The patient had neither fever nor severe abdominal pain that required hospital admission. The patient's lab data showed no electrolyte discrepancy, acid/base derangement, or renal impairment that needed acute hospital inpatient admission status. The intravenous hydration, intravenous pain medications, and clinical monitoring that were provided for this patient in the inpatient setting could have been safely provided in the observation setting. 
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 hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psychotic Episode and depressive symptoms

Treatment: Continued Inpatient Mental Health Services

The insurer denied the continued inpatient mental health services. The denial was upheld.   

This is a female patient with a history of schizoaffective disorder and multiple suicide attempts by overdose. She was admitted to a mental facility due to psychotic and depressive symptoms. It was reported that the patient was homeless and had been experiencing paranoid delusional thinking, depressed mood, feelings of hopelessness, poor sleep, pacing, poor impulse control, impaired insight and judgment, and non-compliance. The patient was treated with Risperidone, Depakote, and Remeron. The patient reported having improving in his symptoms and was discharged.

Per the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia, inpatient admission is clinically indicated for patients with hallucinations, delusional thinking, disorganized behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior. After multiple weeks of medical and psychotherapeutic  intervention there were no reports of further clinical evidence that this patient had psychotic symptoms such as hallucinations, delusions, or disorganized behavior, suicidal or homicidal ideation, intent, or plan, manic symptoms, aggressive, threatening, self-injurious, or agitated behavior, withdrawal symptoms or acute medical instability that warranted continued inpatient treatment. The patient's mood was good, and the patient had more organized, logical and goal-directed thought process. 

The patient denied hallucinations, suicidal or homicidal ideation. The patient had fair energy, improved judgement and insight, good sleep and appetite, and was cooperative and compliant, had good sleep and appetite. The patient was calm and manageable with no behavioral issues. There were no reports that the patient was experiencing hallucinations or delusional thinking or severe depressive symptoms. A couple of days before discharge the patient denied hallucinations, suicidal or homicidal ideation, and the patient was calm and compliant. She had no further acute or serious psychotic symptoms or serious behavioral or mood symptoms. The patient did not exhibit any acute or severe mental health or behavioral symptoms that required 24-hour acute hospital treatment. In addition, the patient did not have any specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital treatment setting as of then or that could not be achieved in a less restrictive level of care as of then. 

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

The carrier's denial of coverage for the continued inpatient mental health services from is upheld.  The medical necessity is not substantiated.