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

The patient has a history of hypothyroidism. He presented to the hospital with an episode of syncope and was admitted. he was discharged the next day. The health plan denied the inpatient hospital admission as not medically necessary. The health plan's determination is upheld. The inpatient admission was not medically necessary as the patient was hemodynamically stable, labs were stable with only mild acute kidney injury, and there was no imaging evidence of stroke. In addition, there was no evidence of acute cardiac arrhythmia, acute seizure, encephalopathy or meningitis or other acute infection.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left leg swelling

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

The inpatient admission was denied. That denial was reversed.

The patient presented to the emergency department with complaints of left leg pain and swelling. Vitals on presentation included: Temperature 36.7 C, blood pressure 122/70, pulse 83, respiratory rate 20, oxygen saturation 96%. 

The patient was admitted for possible left leg cellulitis. He was empirically started on intravenous antibiotics (vancomycin and zosyn). His chest x-ray was negative. Doppler ultrasound was negative for deep vein thrombosis. The patient remained afebrile, was hemodynamically stable, and improved clinically. He was discharged to continue oral antibiotics (doxycycline) as an outpatient.

He was afebrile, hemodynamically stable, but laboratory results showed a mildly elevated WBC. Clinical notes indicate progression of his infection despite outpatient intervention with oral antibiotics, as well as repeat visits to the emergency department. Based on a clear failure of outpatient management, hospital admission for intravenous antibiotics was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission

Inpatient level of care was not medically necessary.

Determination of level of care is primarily dependent on the actual care a patient receives and whether a higher level of acuity is needed 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 were normal times three; there was no evidence of acute ischemia.  Chest x-ray (CXR) was normal.  The physicians' treatment did not reflect any serious concern about the patient's cardiac condition.  Orders did not include medical therapy for ACS such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG).  She was treated with anti-inflammatory medications.

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.  The 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 care.  She was treated with anti-inflammatories.  Tests showed absence of ischemia.  While there is always a potential for an adverse event (and in this case a very low probability), one did not happen and no actual treatment was added.

Milliman criteria requirements were not fulfilled, as there was never any evidence of ACS present, nor any treatment of that diagnosis.

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.

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

The patient had chest pain and was admitted to the hospital. The health plan denied the inpatient hospital admission as not medically necessary. The health plan's denial is upheld. The patient could have been placed in the hospital at a lower level of care. His chest pain was deemed to be unstable angina and a cardiac CTA showed no evidence of a pulmonary embolus, after which he could immediately have had the cardiac catheterization.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with no significant past medical history who was transferred from an outside hospital for management of a perianal abscess. His mother was at the bedside and reported that he had a small boil in the perianal region since 6 months of age. It was evaluated by his primary medical doctor (PMD) with no concern. One day prior to admission the boil became more swollen, red and painful to the touch. His mother denied any discharge from the area.  He had no fever, chills, vomiting, diarrhea or upper respiratory infection (URI) symptoms. There was no history of frequent infections or other skin abscesses. 
The health plan's determination of medical necessity is upheld in whole. The mainstay of his therapy was a bedside I&D which could have been done in an ambulatory setting with a short period of observation post procedure and transition to outpatient care with oral antibiotics. He did not have any markedly elevated inflammatory markers or unstable vital signs to suggest bacteremia/sepsis. He was afebrile with a normal activity level and appetite reported by mother. He tolerated his procedure well and without complication and was discharged soon after the procedure after observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: Inpatient stay 

Summary:
Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary, as this patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain and shortness of breath
Treatment: Inpatient admission

Inpatient level of care was not medically necessary.

This is an elderly male with known CAD presenting with atypical chest pain. It resolved without intervention. His exam and lab findings were not significant for ACS. Cardiology consultation determined that the cause was not cardiac. Medications restarted were appropriate for his history of CAD. 

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed 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 ("abnormal EKG" was consistent with his BiV pacemaker). Chest x-ray (CXR) was normal. The physicians' treatment did not reflect any serious concern about the patient's acute cardiac condition.  Orders did not include medical therapy for ACS such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG). 

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The only cardiac care provided at this admission was telemetry, frequently performed in a lower level of care. The 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 care. This patient had no evidence of CAD. In fact, 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. While it true that the patient had a high risk of having ACS, it was ruled out early and never required intervention. Chest pain resolved spontaneously.

Milliman criteria requirements were not fulfilled as there was never any evidence of ACS or angina present. Having chest pain in itself does not qualify for angina, as seen in the determination by the medical staff that this pain was not cardiac in origin and was not treated as angina. It was appropriate to observe, but no criteria required inpatient level of care.

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.

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

Diagnosis: Viral syndrome
 
Treatment: Inpatient admission, imaging, medications

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

The patient has a past medical history of asthma and gastric bypass surgery. She presented to the emergency department with complaints of flu-like symptoms including fever, diarrhea, cough, and myalgias. Vitals on presentation: Temperature - 98.4F, Blood Pressure - 105/67, Pulse - 92, Respiratory Rate - 18, oxygen saturation - 100% on room air. WBC-10.2, Hgb-9.7, Hct-32.9, glucose-94, creatinine-1.16; lactate-0.8, urinalysis had (+) nitrite.

The patient was admitted for possible viral syndrome. She was empirically started on intravenous antibiotics. Stool grew aeromonas. GI PCR panel was positive for campylobacter. CT scan of the abdomen/pelvis showed enterocolitis involving the terminal ileum and right colon which may be of infectious or inflammatory etiology. The patient improved clinically and was discharged on oral antibiotics; to follow-up as an outpatient.

Based on above findings, patient met criteria for observation level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Scrotal edema
Treatment: Inpatient admission
The inpatient admission was medically necessary.
The patient had been recently admitted with similar symptoms. A hospital admission revealed HCV and low albumin as a potential culprit; however, the patient suffered from worsening symptoms, to the point he could not sit down. In this case, standard of care would dictate admitting such a patient, with the purpose of undergoing a new evaluation (which he did), determining a treatment regimen under observation (Lasix), and discharging with that regimen (Lasix). Thus, standard of care necessitates admitting such a patient. Failure to admit such a patient could lead to unnecessary delay in identification and treatment of the condition, and potentially lead to abscess, DVT, PE (pulmonary embolism), or even death (depending on the cause of the swelling).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: sickle cell disease
 
Treatment: Inpatient admission, diagnostic testing, medications, monitoring

The insurer denied inpatient admission. The denial was upheld.

This case involves a 3 month old with a past medical history of sickle cell disease.  The patient was seen in the emergency department (ED) after having an episode of body twitching and was unresponsive with eyes rolling back for approximately four minutes.  After the episode, the patient returned to baseline and started crying.  In the ED, the patient had a temperature 97.8F, a pulse of 135, respirations of 32 and an oxygen saturation of 100% on room air.  The patient was awake, alert and in no pain.  The patient had no seizure-like episodes noted.  The patient was then admitted for further work-up due to age, history and symptoms.  The patient was started on penicillin as prophylaxis and given intravenous (IV) fluids.  A video electroencephalogram was normal.  The patient was then discharged.

The patient did have a witnessed seizure prior to being seen in the ED.  Following the episode, the patient returned to baseline.  There was no indication that the patient had continued instability.  The patient's condition was appropriate for observational level of care rather than inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female, with a history of asthma and prior history of tobacco dependence, who presented to the emergency department with a 3-day history of coughing and shortness of breath. The cough was productive of whitish sputum. The patient was admitted to the hospital, and started on prednisone, with a plan to treat for 5 days; she was also given concurrent Levaquin due to multiple prior hospitalizations. Bronchodilator therapy was scheduled every 6 hours. The patient was given Robitussin for the cough.
The following day, the patient reported poor sleep, mild headache but improvement in the shortness of breath. She still reported wheezing. Her oxygen saturation was 98% and the rest of the vital signs were stable. Treatment was continued, without changes. Outpatient pulmonology follow-up was recommended. The treatment continued over the following day, oxygenation status remained stable as well. The patient was discharged 3 days post-admission.

The health plan denied the admission as not medically necessary. The health plan's denial is upheld. This patient presented with subjective dyspnea, but no evidence of hypoxia, hemodynamic instability, or respiratory distress. The patient did not require invasive or noninvasive respiratory treatment. There is no documentation that shows that the patient's forced expiratory volume has worsened from baseline. There were no high risk active acute comorbidities such as a pneumonia as evidenced by a clear chest x-ray. There was no alteration of mental status. The patient certainly was not in acute respiratory failure. There was no evidence of hypercarbia. It is not clear from the documentation that the patient has underlying emphysema, as there is no mention of previous pulmonary function tests. She is described as having asthma, but the patient has no peak flows documented, to determine if she is below her baseline. The patient was treated with oral steroids and antibiotics, and did not fail observation treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
This patient presented with exertion chest pain that was of new onset over the preceding weeks.  She was noted to be hypertensive on examination. No other abnormalities or findings consistent with an acute coronary syndrome (ACS) were noted.  Based on history and presentation alone, this patient had a low short term risk of death and nonfatal cardiac ischemia. (Reference1)  
The patient underwent exercise stress testing and had a Duke treadmill score of +4.  No evidence of ischemia was noted on myocardial imaging. These findings are consistent with a low one year mortality and a low probability of significant coronary artery disease. (Reference 2) Utilizing the HEART score she is considered low risk (three points). (Reference 3)  Utilizing the TIMI risk score, she also had a low risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1). (Reference 4) Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (Reference 4).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction [MI], need for percutaneous coronary intervention [PCI], need for coronary artery bypass grafting [CABG], or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. Ultimately this patient underwent myocardial perfusion imaging that revealed no evidence of ischemia- confirming the aforementioned low risk stratification.  In conclusion, the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient was brought to the emergency department by a friend with worsening symptoms of depression in the context of increased alcohol use and suicidal ideation.  The patient had taken ten sleeping pills in an effort "to sleep."  The patient had thoughts of death and depression and anxiety had triggered symptoms related to chronic post-traumatic stress disorder (PTSD) including nightmares.  The patient was admitted to the acute inpatient psychiatric level of care and was treated with supportive measures and safety monitoring and started on a medication regimen.  The patient had the opportunity to participate in psychotherapy, group activities, and participate in other milieu interventions.  The patient was switched from Zoloft to Effexor XR that was titrated as clinically appropriate to a dose of 187.5 milligrams (mg) with the addition of low dose aripiprazole.  The patient was provided motivational enhancement therapy and the opportunity to attend 12-step recovery groups to address the alcohol use disorder.  Throughout the hospital course the patient had not exhibited severe psychiatric symptoms including psychosis, severe cognitive impairment, mania, or thought disorder, and had not shown active suicidal ideation or aggressive impulses or violent intent.  The health plan's determination is upheld.

The patient's continued treatment for depressive disorder, PTSD and other medically necessary treatments could have been safely and effectively provided at a lower level of care.  Specifically, the patient was medically cleared prior to admission for psychiatric care.  Following admission, the patient had been treated for the mood disturbance and associated symptoms of anxiety/insomnia/nightmares and functional impairments with improvement in symptoms and functioning and did not require continued acute inpatient level structure or monitoring during the time interval under review.  There was no further risk for suicidal behavior or documented symptoms that would have warranted continued assessment, safety monitoring and treatment in an acute inpatient setting.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Substance abuse
 
Treatment: Inpatient substance rehabilitation treatment

The insurer denied the continued inpatient substance rehabilitation treatment. The denial was modified.

This patient is a male who was admitted to inpatient substance residential treatment as he was court mandated for 28 days of this treatment. He was using cocaine a few times per week with a 5 year history of use, and was abusing Xanax. He had a recent inpatient substance detoxification and an intensive outpatient program treatment. He continued to relapse. He continued to use substances despite past negative consequences. He had anxiety and was self- medicating with substances of choice. 

In this case the patient was considered in need of 24-hour substance rehabilitation treatment for at least 3 months as he continued to relapse despite past inpatient substance detoxification and Intensive Outpatient Program (IOP) treatment. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he met criteria for inpatient substance rehabilitation treatment as he continued to use multiple substances including large amounts of cocaine and Xanax despite past inpatient substance treatment and Intensive Outpatient Program (IOP) treatment. He was at risk for overdose and was considered a danger to self and others due to use as he had multiple arrests for drug related charges, lost his job, was homeless, was self-medicating anxiety, and could not maintain abstinence. The 28 days in this inpatient treatment was not considered enough treatment due to his significant amount of drug use and many negative consequences to use. 

The medical necessity for the continued residential treatment substance abuse rehabilitation level of care for the first 92 days is substantiated. The insurer's denial is modified. Approve the first 92 days; deny remaining dates.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tachycardia
Treatment: Inpatient stay 
The inpatient stay was not "medically necessary".

Summary:
The patient is a woman with no known past medical history presented to for elective electrophysiologic study and possible ablation.  She was previously evaluated for narrow complex tachycardia.  The patient presented to the hospital and underwent successful EP study and ablation of typical AV node reentry tachycardia.  The procedure was without complication.  

This patient underwent successful electrophysiologic study with ablation of typical AV node reentry tachycardia.  Following a period of post procedure observation, the patient was discharged. Several studies have demonstrated both feasibility and safety of same day home discharge following radiofrequency ablation. In one study, a cohort of over 1300 individuals undergoing catheter ablation were discharged on the day of their procedures following a six hour observation period.  (Reference 1) The authors of this study concluded that more than 90% of patients presenting for elective EP study with ablation could be discharged the same day.  In a second study of 11,000 patients undergoing catheter ablation of supraventricular tachycardia, the median length of stay following ablation was one day. (Reference 2).  In this case, a successful and uncomplicated ablation was performed.  The patient was observed post procedure for several hours and discharged the next day. Treatment at a higher level of care was not medically necessary.