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

Diagnosis: Respiratory System (Asthma)
Treatment: Inpatient Hospital

Summary: This patient has a history of three previous Emergency Room (ER) visits for wheezing. He had a cough and runny nose for three days and was treated at home by his mother with several treatments of albuterol for his persistent cough. When he began to have evidence of increased work of breathing, he was taken to the ER for additional treatment. In the ER, he was noted to be wheezing with tachypnea and increased work of breathing. He was treated with three doses of inhaled Combivent and prednisone. A respiratory viral panel was positive for the Respiratory Syncytial Virus (RSV) virus. A chest x-ray did not show evidence of pneumonia. After treatment in the ER, he continued to have wheezing and abdominal retractions, and the decision was made to continue treatment with albuterol every two hours. When his increased respiratory effort continued despite frequent administration of albuterol, the decision was made to admit him to the hospital for ongoing albuterol administration every two hours with a diagnosis of status asthmaticus.

The insurer has denied the inpatient hospital admission as not medically necessary. The denial was reversed. 

The patient was treated appropriately in the ER, and when his respiratory distress did not respond to vigorous treatment, the decision to admit him to the hospital was appropriate and consistent with the standard of care for status asthmaticus. He had not responded to home treatment, and because he required albuterol administration every two hours, he could not have been safely treated at home. The medical necessity is substantiated.
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 for evaluation of atypical chest pain, as well as neurological symptoms, consistent with cervical radiculopathy. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. The patient was evaluated by cardiology, and no further ischemic work-up was planned. There was no evidence of acute myocardial infarction, ACS, decompensated CHF (congestive heart failure), malignant arrhythmia or acute CVA or seizure. 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 a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart block, trisomy 21
Treatment: Inpatient admission
The inpatient admission is medically necessary.
The patient was admitted overnight due to his underlying rhythm which was 50 beats per minute (and now he did not have a functioning pacemaker), clotting issues and his refusal to lay flat in recovery.  
A patient with heart block and without a pacemaker needs to be in an inpatient setting so a temporary pacemaker can be placed if needed.  It was in the best interest of the patient to be admitted as an in-patient.
Appeal type: Medical necessity
Decision: Upheld

The patient was born with hypoplastic left heart syndrome who underwent a Norwood stage I procedure. Cardiac catheterization demonstrated multiple levels of aortic arch obstruction with hypoplasia of the branch pulmonary arteries. Repeat cardiac surgery was then performed which included aortic arch reconstruction, pulmonary artery arterioplasty and revision of the modified left Blalock Taussig (BT) shunt. Due to severe cyanosis, the patient was placed on extracorporeal membrane oxygenation (ECMO) support for 3 days and eventually discharged home in stable condition. Other noted complications following this admission included a paralyzed left vocal cord, delayed sternal closure and possible renal tubular acidosis. It appears that the patient was doing well as an outpatient and enrolled in the single ventricle monitoring program without any additional hospital admissions. Additional cardiac surgery with placement of a bidirectional Glenn shunt and takedown of the modified BT shunt was performed. An elective cardiac catheterization was then performed under general anesthesia and which demonstrated areas of stenosis within the cavopulmonary connection and left pulmonary artery which were successfully alleviated via balloon angioplasty and endovascular stenting. The patient was successfully extubated in the catherization laboratory with acceptable oxygen (O2) saturations, vascular hemostasis was maintained without complications and all vital signs were considered stable.The patient was started on his usual nasogastric (NG) feeding regimen and was ready for discharge home the following morning without complications. Inpatient hospital admission was not medically necessary for this patient. Post catheterization observation and monitoring overnight at a lower level of care would have been appropriate for this patient following this type of interventional catheterization procedure.  Although this patient has complex congenital heart disease, the cardiac catheterization demonstrated appropriate hemodynamics and the interventional aspect of the procedure was deemed uncomplicated. Patients with hypoplastic left heart syndrome post bidirectional Glenn shunt surgery are typically much more stable from a hemodynamic standpoint when compared to post Norwood stage I physiology. The introduction of a pulmonary artery stent in this particular situation would not increase the patients risk post procedure except for the possibility of a vascular complication which was not evident at the conclusion of the case. The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

The patient has a past medical history significant for psoriasis on Stelara, osteoarthritis, degenerative disk disease, and newly diagnosed ovarian tumor, and presented to the emergency department with chief complaint of nausea and dizziness. Given concerns for diverticulitis in an immunocompromised patient, the patient was subsequently admitted to the hospital and was started on intravenous (IV) fluids and IV antibiotics and seen by gyn/onc and general surgery. Ultimately, the patient was discharged on oral antibiotics with plan to follow up with gyn/onc and colorectal surgery for diagnostic laparoscopy. The health plan's determination is overturned, in part.

This patient presented with abdominal pain, leukocytosis and imaging suggestive of diverticulitis versus malignancy. Though the patient did not have fevers, chills, bowel perforation, or other complaints, the patient was immunocompromised being on Stelara, which placed the patient at significant risk of progressive infection and sepsis. In the setting of immunocompromise and inability to control pain at home with Percocet, it was reasonable to anticipate the patient might require two midnights in the hospital and to keep the patient until her leukocytosis had resolved. Acute inpatient admission was medically necessary and reasonable, in part.
Appeal type: Medical necessity
Decision: Upheld

The patient presented with a chest pain with radiation and associated diaphoresis. The documents confirm that the history is limited but does confirm the patient has a history of diabetes, coronary disease status/post (s/p) percutaneous coronary intervention (PCI) and hypertension.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient's presentation for chest pain was felt to be due to cocaine and there was no evidence of a heart attack. Typically, a patient with cocaine induced chest pain is monitored for an observational period of time when no additional acute medical problems that warrant inpatient medical stay are present such as heart failure, abnormal rhythms or hemodynamic abnormalities. The patient could have been observed at a lower level of care and transferred to a facility that handled mental health challenges whether in an acute or semi-acute setting based on psychiatric evaluation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems (elevated blood pressure)
Treatment: Inpatient Hospital

Summary: This patient presented to the Emergency Department (ED) with complaints of elevated blood pressure (50 days after a normal vaginal delivery). She reported a blood pressure of 140/100. She was admitted and started on Labetalol and Procardia. The patient was also given magnesium therapy for seizure prophylaxis. Her blood pressure readings settled and the patient requested to be discharged home. She was discharged in stable condition to follow up with her Obstetrician as an outpatient.
 
The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.
 
Delayed postpartum preeclampsia can be defined as signs and symptoms of the disease leading to readmission, more than two days, but less than six weeks after delivery, although various other definitions have been used.  Signs and symptoms can be atypical. Risk factors for delayed postpartum preeclampsia appear to be similar to those for preeclampsia during pregnancy, but some patients have no risk factors. The diagnosis of preeclampsia is based on the new onset of hypertension and either proteinuria or end-organ dysfunction after 20 weeks of gestation in a previously normotensive woman: 1. Systolic blood pressure 140 mmHg or diastolic blood pressure 90 mmHg, and 2. Proteinuria 0.3 grams in a 24-hour urine specimen or 3.	Protein: creatinine ratio 0.3, or 4. Signs of end-organ dysfunction (platelet count <100,000/microliter, serum creatinine >1/1 mg/dL or doubling of the serum creatinine, elevated serum transaminases to twice normal concentration). Based on the above, this patient did not have preeclampsia. She did have elevated blood pressure that needed control. Note that her laboratory evaluation did not show any anomaly. The patient could have been observed for a few hours in the ED, and once the provider ascertained that there were no medical emergencies, she could have been sent home and followed as an outpatient for blood pressure control. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

The patient presented to the emergency room due to fast breathing and shortness of breath. Prior to presentation the patient developed a runny nose and cough. The cough worsened and the patient began to retch along with the cough. The patient was seen by the primary care physician who sent the patient to the emergency department by ambulance for possible pneumonia and need to intravenous fluids. The health plan's determination is overturned.
This is a patient who presented with respiratory symptoms and decreased oral intake, and who vomited in the emergency department. The laboratory values included an elevated white blood count as well as a concentrated urine specific gravity of 1.025. The patient continued to have tachycardia of unclear etiology despite receiving appropriate intravenous hydration. In fact, there was some concern for myocarditis and an EKG was obtained. The patient required ongoing hydration in an inpatient setting, with close monitoring for potential deterioration of clinical status and to allow for prompt intervention as needed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left hip pain 
Treatment: 16 additional physical therapy visits

Summary:
The ongoing therapy in question was not medically necessary, as there would were no indications that he had impairments or issues that he could not have further addressed with independent exercise.  There were no indications that the therapy in question was medically necessary for further improvements in his ability to participate in work.  No marginal difference in clinical course or functional outcomes would have been reasonably expected with ongoing formal therapy versus an independent exercise program and return to activities as tolerated, based on the available records.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Decompensated liver cirrhosis/ascites and acute/chronic kidney disease 
 
Treatment:  Inpatient Admission and paracentesis x 2

The insurer denied the coverage.  The denial was upheld.

This is a female patient presented to the Emergency Room for a chief complaint of worsening abdominal bloating that had been happening for 3 weeks.  The patient reported the abdominal bloating was not associated with any abdominal pain.  She denied nausea, vomiting, diarrhea, fever, and chills.  The patient had a past medical history significant for untreated hepatitis C, diabetes mellitus type 2, hypertension, substance abuse with the patient reporting using heroin the previous Friday.  The patient reported that she first developed ascites in mid-2018.  She was hospitalized in late 2018 and was there for about 10 days, and had an EGD and a paracentesis while an inpatient.  She was given a prescription for lactulose at the time of discharge.  

Liver function test revealed an albumin of 2.6, bilirubin of 0.6, and alkaline phosphatase of 95, an ALT of 20, an AST of 45, and a protein, total of 6.9.  The gastrointestinal exam was positive for abdominal distention, and negative for abdominal pain, anal bleeding, anorexia, constipation, diarrhea, hematemesis, hematochezia, melena, nausea and vomiting.

The insurer has denied coverage for the inpatient hospital services as not medically necessary.  However, observation criteria were met and approved.

The MCG general admission criteria include hemodynamic instability, hypertension requiring inpatient treatment, acute cardiac or peripheral ischemia, cardiac arrhythmias, respiratory abnormalities, neurologic abnormalities, severe physiologic disorder remaining after emergency or observation level care.  The MCG liver disease complication clinical indications for admission to inpatient care include hepatic encephalopathy that is moderate to severe or insufficiently responsive to observation care treatment, hemodynamic instability, tachypnea, suspected infected ascites as evidenced by fever, abdominal pain or tenderness not relieved by paracentesis, high white blood count (WBC), altered mental status, AST or ALT level 15 times upper limit of normal or higher, chronic liver disease complicated by an acute exacerbation as indicated by total serum bilirubin of 5mg/dL or more, elevated prothrombin time to more than 50% above normal, metabolic abnormalities that are severe or persist beyond observation care such as hypoglycemia, acidosis and/or hyponatremia.

She did not meet the guideline criteria for a liver disease complication inpatient admission level of care.  The carrier's denial of coverage for the inpatient hospital services is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

This patient presented to the ER for further evaluation/management of shortness of breath, cough and fatigue. His intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. His examination was non-focal with no significant abnormalities noted including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen. Laboratory and ECG testing were also within normal limits, with the exception of mild hyponatremia and thrombocytopenia, but no other evidence of acute end organ damage. 

Imaging with chest x-ray and chest CT revealed findings consistent with PNA. The medical records indicate that this patient was admitted to the inpatient medical service in stable condition, where he received treatment with broad spectrum IV antibiotics, nebulized bronchodilators and supportive care with IV fluids. He responded well to the prescribed therapies, and he was subsequently discharged in stable condition. There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Overbite and blocked canines
Treatment:  Braces
The braces are medically necessary.

The patient has several issues that require orthodontic treatment.  First, she has a very deep overbite.  Her lower teeth impinge on the palatal gum tissue behind her upper front teeth.  This is an "automatic qualifier" on the handicapping scale.  Also, the patient has both of her upper permanent canines "blocked out," meaning there is no room for these teeth to erupt in their proper positions.  Without the canines in their proper positions, there can be no "canine guidance," which means that during the chewing cycle, her teeth are going to grind together improperly and wear themselves down.  These two issues, an overclosed bite and no canines in their proper position, will, over time, predispose this patient to TMJ (temporomandibular jaw) problems.  The TM joints will be stressed and will cause discomfort.  They will most probably start to degenerate over time, adding to the discomfort.  Between the early wearing down of her teeth and the TMJ issues, this patient is in definite need of orthodontic treatment.  It is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Bipolar Disorder and Post-traumatic Stress Disorder

Treatment:  Residential inpatient substance abuse treatment, medication management

The insurer denied continued inpatient substance residential treatment. That denial was reversed.

This patient was admitted to inpatient substance residential treatment due to opioid use. He also had other diagnoses reported including Bipolar Disorder and Post-traumatic Stress Disorder (PTSD). He was attending individual and group therapy and took Lithium, Remeron, and Clonidine, as well as Suboxone. He tested positive for codeine and morphine. He was still in this residential treatment at the time of the denial and was working on trying to get housing.

This patient did not have the reported supports to be safely and effectively treated outside of this substance residential treatment. The American Psychiatric Association (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, this patient was still considered in need of 24 hour residential treatment, as it was reported that he met with the housing specialist the day prior. It was reported that he needed housing and he was considered to be in need of more structure in this 24 hour setting to work on triggers and coping skills. He had struggled to manage stress and family relationships which contributed to his use of substances. 

In this case, this patient needed more time in this setting to work on the above mentioned issues and needed a supportive environment, as well as housing. Without that, he was considered to be at risk for relapse, and outpatient substance treatment was not considered to be enough treatment at that time. He required continued inpatient substance residential treatment to give him the best opportunity to stop using substances and maintain abstinence, learn better coping skills and relapse prevention skills, and to better identify relapse triggers. He had comorbid psychiatric symptoms and diagnoses as well which put him at further risk as he was being treated with Lithium and Remeron for mood symptoms. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he met criteria for substance residential treatment as without this structured and supervised therapeutic residential treatment, he likely would have relapsed quickly.
Appeal type: Medical necessity
Decision: Upheld

The patient presented with shortness of breath and palpitations. This was associated with chest pressure and tingling of left arm. The patient's blood pressure was 130/70 millimeters of mercury (mmHg) and a heart rate of 200 beats/minute. The oxygen saturation was 100% on room air. The cardiac exam revealed a rapid heart rate and was otherwise unremarkable. Prior to obtaining an electrocardiogram, the patient's rhythm spontaneously converted to sinus. The electrocardiogram, when performed, showed sinus tachycardia at 101 beats/minute, without ischemic changes. Serum troponin level was normal. Chest x-ray showed no acute pathology. The patient's symptoms resolved once the arrhythmia terminated. The patient was admitted to the hospital. An echocardiogram was performed and showed normal left ventricular systolic function and no significant valve disease. The patient was started on metoprolol and discharged home with plans for outpatient cardiology follow-up. The health plan's determination is upheld.

This patient presented with tachycardia and dyspnea that was thought to be due to paroxysmal supraventricular tachycardia (PSVT). Before an electrocardiogram could be performed, the tachycardia terminated. While there are no established guidelines regarding disposition for patients presenting to the emergency department with PSVT, most authors suggest that, in the absence of serious comorbidities, syncope, or rapid pre-excited atrial fibrillation or flutter, hospital admission is not necessary for adults whose PSVT is converted to sinus rhythm without complications. 

In summary, this single episode of hemodynamically stable PSVT that terminated spontaneously did not require an inpatient admission. If overnight monitoring was thought to be necessary, this could have been accomplished at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System (Bronchitis)
Treatment: Inpatient Hospital

Summary: This patient with a past medical history significant for bronchitis and pneumonia presented to the emergency department (ED) with complaints of worsening cough for two to three months. Vitals on presentation included: temperature max-38 C, blood pressure-103/68, pulse-100, respiratory rate-16, oxygen saturation-99%. Laboratory values were notable for the following: white blood count-9.0, hemoglobin-13.8, hematocrit-40.3, creatinine-0.92, glucose-88, procalcitonin <0.05, and rapid influenza A, B negative. The patient was admitted to rule out infection. He was empirically started on antibiotics. Chest x-ray was negative. Chest computed tomography (CT) scan showed no active disease. The patient remained afebrile, hemodynamically and clinically stable. He was discharged on an oral antibiotic (azithromycin).

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

According to the documentation, the patient presented to the ED with chronic cough, despite outpatient oral antibiotics. He had a low grade fever (100.4), otherwise he was hemodynamically stable with unremarkable laboratory results including normal white blood count, lactate, and procalcitonin. Additionally, chest x-ray and chest CT scan showed no abnormalities. The clinical impression was bronchitis and/or possible viral syndrome. There was no evidence for an acute systemic infection. The patient was able to tolerate oral intake. The medical necessity for the inpatient admission is not substantiated.