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

Cardiac/Circulatory Problems - Other
Inpatient Hospital

The patient is a male with a history of hypertension, hyperlipidemia, congestive heart failure, polysubstance abuse and hydrocele. He presented to the emergency department complaining of one month of dyspnea, neck pain, lower extremity edema and worsening scrotal swelling. He reported noncompliance with his medications. His blood pressure was 181/148 millimeters of mercury (mmHg) with a heart rate of 92 beats/minute. His respiratory rate was 24/minute with a room air oxygen saturation of 99%. His physical exam was remarkable for labored breathing, jugular venous distension, lower extremity edema and marked scrotal swelling. His electrocardiogram showed sinus rhythm with anterior T wave inversions. His serum troponin level was elevated. His N-terminal pro brain natriuretic peptide (BNP) level was 12,912 pg/ml. Scrotal ultrasound showed massive bilateral hydroceles. He was treated with intravenous furosemide and hydralazine and admitted to the hospital for management of decompensated heart failure and hypertensive urgency. The following day the patient noted less dyspnea and edema. His blood pressure was 141/78 mmHg. He had persistent jugular venous distension and improved but persistent edema. Furosemide and hydralazine were continued. An echocardiogram showed a left ventricular ejection fraction of 25% and severe pulmonary hypertension. The patient eloped from the hospital. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

Yes, an inpatient level of care was medically necessary. This patient, with severe left ventricular systolic dysfunction, presented in acute decompensated heart failure (ADHF). His serum troponin level was elevated. In patients with ADHF, elevated serum troponin is associated with an increased short- and long-term mortality. In-hospital mortality in this cohort has been shown to be nearly three times that of patients with normal troponin levels (8.0% vs 2.7%). In addition, his N-terminal proBNP level was markedly elevated. In the Acute Decompensated Heart Failure National Registry (ADHERE) registry, admission N-terminal proBNP values in this range were associated with 2.23-fold increase in in-hospital mortality compared with BNP in the lowest quartile (less than [<] 430 pg/mL), even after adjustment for potential confounders. Based on this patient's Ottawa Heart Failure Risk Score, he was at high risk for major adverse cardiac events, including death, myocardial infarction and need for mechanical ventilatory support. An inpatient level of care, with the ability to intervene emergently if needed, was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Musculoskeletal: other
Durable Medical Equipment (DME) 

The patient is a male who presented with a pectus carinatum deformity. According to the consultation report with the pediatric surgeon, the deformity worsened over his recent growth spurt. On exam, the defect was asymmetric to the left side but the surgeon reports that there is good mobility (flexibility) of the chest wall.

The health plan's determination is overturned. The Chest Brace is medically necessary. The presence of a skeletal deformity has adverse effects on psychosocial adjustment and development in youth. In those patients who can benefit from bracing, it is therefore necessary to provide effective therapy. This child has a flexible deformity, as indicated in the surgeon's note.
In the UpToDate article, the author clearly indicates that bracing is indicated due to reasonable efficacy for younger teenagers with flexible chest walls. The surgeon did indicate in his note that the patient had mobility of the chest wall and would be a good candidate. Findings from research in this patient population from Cincinnati Children's, a top 3 children's hospital is entirely consistent with the observation that the vast majority of patients with this deformity benefit from bracing.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pulmonary embolism

Treatment:  Inpatient Admission

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

This is a male patient with a medical history hypertension (HTN), diabetes mellitus (DM), coronary artery disease (CAD) status post myocardial infarction (MI), and end stage renal disease (ESRD) on dialysis, and a recent de clotting of his arteriovenous (AV) fistula.  He presented to the emergency department (ED) with complaints of intermittent left sided chest pain with left arm pain, numbness and intermittent cold for one week.  The patient's vital signs at presentation were temperature (T) 98.2 F, respiratory rate (RR) 18, blood pressure (BP) 152/74 mm Hg and heart rate (HR) 72.  Oxygen (O2) saturations were 98%.  The patient's physical exam was unremarkable.  White blood cell (WBC) count was normal.  Hemoglobin (Hb) was 11.7 and BUN/ Creatinine 49/8.08.

Laboratory work-up was performed with normal results.  He had a chest x-ray that showed no infiltrates.  Electrocardiogram (EKG) was performed that showed normal sinus rhythm.  The patient underwent a computed tomography (CT) Angiogram, which revealed a sub segmental occlusion of left upper lobe (LUL) pulmonary artery; he was diagnosed with a pulmonary embolism.  He was started on intravenous (IV) Heparin.  He was consulted by vascular Surgery for evaluation for his complaints of coldness in his left upper extremity.  A deep vein thrombosis (DVT) study was performed with normal findings.  He continued to receive his maintenance hemodialysis and remained hemodynamically stable.  He was discharged home on Eliquis. 

This patient had a mild pulmonary embolism (PE) with a low clot burden.  He did not need acute hospitalization.  He could have been placed in Observation status while diagnostic studies and treatment were initiated.  The patient could have been discharged on oral (PO) Eliquis after a period in Observation status.  The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld.
Appeal type: Medical necessity
Decision: Upheld

Gynecological
Inpatient stay

This is the case of a patient with a past medical history of tubal ligation, sickle cell trait, menorrhagia, and chronic anemia, who presented to the emergency department with right-sided flank and abdominal pain with associated nausea and vomiting. There were no reports of significant ongoing vaginal bleeding. On presentation, the patient was noted to be afebrile with blood pressure 118/73, heart rate 84, respiratory rate 19, and saturation of 100% on room air. Exam otherwise noted mild tenderness in the left lower quadrant. A computed tomography (CT) of the abdomen pelvis noted adnexal cystic mass in the upper pole of the right pelvis measuring 7.9 by 4.8 by 7.9 centimeter (cm). Ultrasound noted large hemorrhagic cyst. The patient was subsequently brought into the hospital with assessment that the patient had anemia secondary to hemorrhagic cyst and menorrhagia and with plans for blood transfusion and obstetrics/gynecology (OB/GYN) consult. After presentation, the patient is noted to have remained hemodynamically stable without hypotension or tachycardia, to have an appropriate increase in hemoglobin to 8.4 after 2 units of packed red blood cells (PRBCs) were administered, and no significant vaginal bleeding was noted. The health plan's determination of medical necessity is upheld in whole. This patient presented with anemia in the setting of sickle cell trait, hemorrhagic cyst, and known menorrhagia. Patient was hemodynamically stable, did not have ongoing bleeding requiring an emergent procedure such as hysterectomy or uterine artery embolization, and the  hemoglobin responded appropriately to 2U PRBCs. The patient furthermore did not have significant pain requiring frequent intravenous (IV) pain medications and failing outpatient care. It is unclear why the patient could not be safely cared for at a lower level of care. In the absence of hemodynamic instability, ongoing bleeding requiring repeated transfusions and hemoglobin that did not improve with transfusion, need for emergent hysterectomy, and with no other unstable medical issues, it is unclear why inpatient care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Rectal Bleeding, Anemia
 
Treatment:  Inpatient Admission

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

This is a patient who has a history of anemia and hemoglobin as low as 5.4.  She presented to the Emergency Department (ED) with complaints of bloody diarrhea.  Her vital signs were stable, although she had a mild tachycardia.  The abdominal exam was benign.  A laboratory work-up was performed that revealed her hemoglobin was 4.7.  Her stool was tested and was positive for blood.  Gastroenterology consulted on the patient with recommendations for endoscopic testing.  She received a blood transfusion with repeat hemoglobin of 6.8.  The patient refused further blood transfusions.

Clinical indications for admission for Lower Gastrointestinal Bleeding (M-182) include ongoing active bleeding, failure to control bleeding after a colonoscopy, coagulopathy, hemodynamic instability, severe thrombocytopenia and anemia with signs of cardiac ischemia.  The patient did not have these conditions.  At the time of admission she was found to have brown stool that was only faintly heme positive. 

This patient had rectal bleeding and anemia.  She was not actively bleeding in the hospital.  The hemoglobin improved after a transfusion.  She was stable to have received the transfusion with observation status.  Afterwards, a repeat of the endoscopic testing could have been performed on an outpatient basis.  She did not meet MCG criteria for admission for lower gastrointestinal bleeding.  

The healthcare plan acted reasonably and with sound medical judgment.  

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

Diagnosis:  Asthma
Treatment:  Inpatient admission

The inpatient admission was medically necessary.

The patient is a female whose inpatient admission is under review.  The patient has a history of human immunodeficiency virus (HIV), asthma, nonischemic cardiomyopathy (CM), obstructive sleep apnea (OSA), hypertension (HTN), and gastroesophageal reflux disease (GERD).  She presented with two days of fever and cough.  Positive for dyspnea on exertion (DOE), wheezing and productive cough.  Her medications included: Singulair, Symbicort, prednisone, and Complera.

In the emergency room (ER):  Temperature (T) - 100.5; Respiratory rate (RR) - 27; Blood pressure (BP) - 145/95; Pulse (P) -116; Oxygen saturation (O2 sat) - 99% room air; General - obese; Cardiovascular system (CVS) - tachycardia; Pulmonology - talking in full sentences, no stridor, bilateral wheezing, no retractions; Abdomen - normal; White blood cell (WBC) - 19.52 (high); Neutrophil - 79.8% (high); Hemoglobin (Hg) - 12.5; Hematocrit (HCT) - 38.6; Platelets (PLT) - 254; Sodium (Na) - 143; Potassium (K) - 4.0; Chloride (Cl) - 103; Carbon dioxide (CO2) - 27; Blood urea nitrogen (BUN) - 16; Creatinine (Cr) - 0.84; Glucose - 85.

Respiratory viral panel (RVP) was positive for entero/rhinovirus.  Computed tomography (CT) of the chest revealed no pulmonary embolus; positive for atelectasis.

The patient was evaluated in the ER, and determined to have sepsis, in addition to asthma exacerbation and viral infection.  She was given intravenous (IV) antibiotic, and admitted.  She quickly improved, and it was determined that all of her signs and symptoms were from an asthma exacerbation, and she was subsequently discharged.

Typically, a patient with asthma exacerbation due to a virus does not need admission.  However, standard of care would require admission, IV treatment, and intensive inpatient observation in a patient who presents with a similar constellation of signs and symptoms for the following reasons:  1) An extremely elevated WBC count in the presence of fever and sepsis. As these are typically bacterial, and potentially fatal, outpatient treatment and follow-up are not the standard of care, and 2) A host of medical conditions that can adversely affect the lungs, lowering potential reserves and raising chance of complications from sepsis, including asthma, non-ischemic cardiomyopathy, obstructive sleep apnea, and obesity.

Thus, this admission was warranted, supported by standard of care.  Failure to admit such as a patient can lead to loss of function, respiratory failure, septic shock, or even death.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who presented to the emergency department with persistent fevers and rash. He was well until approximately 5 days prior to admission when his mother noticed a red rash starting on his legs. The rash progressed to involve his back and stomach as well as his hands and feet. He also developed fever with a maximum temperature of 103.6 degrees Fahrenheit (F). He had been receiving ibuprofen at home with little relief, and he continued to have fevers. He was tolerating some oral intake, but had intermittent episodes of decreased activity. He was seen at his primary care provider's office where there was a concern for Kawasaki disease, and he was referred to the emergency department for further care.
The health plan's determination is overturned. The patient required prompt initiation of IVIG therapy along with high-dose aspirin in an inpatient setting to treat his symptoms and prevent the potentially serious complications of Kawasaki disease. He also had a blood culture sent that was pending. He required consultation from both infectious disease and cardiology, along with cardiorespiratory monitoring with further treatment as needed. Prompt treatment with intravenous immune globulin (IVIG) reduces the prevalence of coronary artery aneurysms fivefold in patients with Kawasaki Disease. Despite its advantages, IVIG is a potentially toxic intervention, and requires careful monitoring.
Appeal type: Medical necessity
Decision: Overturned in Part

The patient is a male, who had presented to the emergency department for evaluation of cough, wheezing, subjective fever, and chills. He was tachypneic, afebrile, hemodynamically stable, and had normal room air oxygen saturation. Physical examination was significant for mild tachypnea, ability to speak full sentences, and bilateral expiratory wheezes. Chest x-ray was negative for acute cardiopulmonary process. There was some improvement in the patient's symptoms with emergency department treatment. However, persistence of exertion dyspnea was noted, prompting admission for management of asthma exacerbation.

Treatment included systemic glucocorticoid and inhaled bronchodilators. There was improvement in the patient's clinical symptoms and peak expiratory flow rate (PEFR). He was transitioned from intravenous to oral glucocorticoid per pulmonologist recommendation and was discharged.

The patient was readmitted following presentation to the emergency department for evaluation of shortness of breath, cough, and post tussive vomiting following dust inhalation at work. He had been compliant with prednisone prescribed at discharge. There was mild tachypnea and tachycardia. He was afebrile and room air oxygen saturation was normal. Chest auscultation was significant for bilateral wheezes. Review of laboratory data was significant for leukocytosis with a left shift. Chest x-ray was unremarkable. The patient improved with systemic glucocorticoid and inhaled bronchodilators. He was discharged.

The health plan's determination is overturned, in part.

No, the inpatient stay was not medically necessary for the first admission.

The patient presented with asthma exacerbation. There was rapid improvement in PEFR following admission. There was no hemodynamic instability, hypoxia, hypercapnia, respiratory distress, altered mental status, need for ventilatory support, associated pneumonia, presence of risk factors for asthma-related death, or concern for poor adherence with asthma medication following discharge. The patient continued to improve and was discharged. Documentation does not support inpatient level of care. The patient could have been adequately managed at a lower level of care.  
Yes, the inpatient stay was medically necessary for the second admission. 

The patient was at risk for asthma death due to recent hospitalization for asthma exacerbation and ongoing use of oral corticosteroid. Aggressive treatment at inpatient level of care with intravenous glucocorticoid and inhaled bronchodilators, as well as close monitoring of response to therapy was appropriate in this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient admission

The proposed treatment, inpatient admission, was not medically necessary for this patient in keeping with NY State OASAS LOCADTR 3.0 Guidelines/Criteria.

The inpatient substance abuse rehabilitation treatment, in this case scenario, was amenable to treatment at a lower level of care. The patient was externally motivated and able to effectively engage in rehabilitation services, and, the patient did not need the structure or 24-hour monitoring of an inpatient setting in order to safely and effectively participate in rehabilitation substance abuse treatment. There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted inpatient level services and treatment. Moreover, the patient demonstrated his motivation for continued involvement in the substance use disorder treatment during his detoxification, as noted in the clinical summary. Thus the requested benefit of inpatient admission was not medically necessary for this patient.

This answer is consistent with prevailing standards of professional practice, ASAM Criteria, and the scientific literature, referenced below, as well as New York State instruction for medical necessity reviews together with the NY State OASAS LOCADTR 3.0 Criteria, applicable in this case.

The structure and intensity of services necessary for a successful rehabilitation/substance use disorder treatment can be/could have been effectively provided at a lower level of care in a less restrictive treatment setting with sober supports. There is no evidence that inpatient level structure and 24-hour monitoring is medically necessary for a successful outcome with regard to the dates of service under review.  And, there were no biomedical, psychiatric or general medical issues that warranted the admission and the continued inpatient level treatment in this case scenario.
 
Thus, as the health plan asserts, the patient's substance use disorders were amenable to treatment at a lower level of care in this case scenario, and the health plan's determination of medical necessity was consistent with the application of NY State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below, as well as ASAM Patient Placement Criteria and the scientific literature and published guidelines, also referenced below.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female who completed detoxification treatment and was admitted/transferred to inpatient level services for rehabilitation substance use disorder treatment of opioid (heroin) use disorder; the patient had been using up to 5 bags of heroin per day with intranasal administration. She was also tobacco dependent. Her referral was prompted by increasing symptoms of depression and anxiety with a past diagnosis of schizoaffective disorder and unspecified depressive disorder.

The inpatient level substance use disorder rehabilitation treatment included the opportunity to participate in groups, individual counseling, education and 12-step recovery groups with peer support. Comfort medications were available as needed, and she was prescribed vitamins and nicotine replacement therapy. She was started on Lexapro and Seroquel to address her psychiatric disorders. Her clinical course was benign, and she engaged with treatment. The patient was transferred to a sister facility for continued inpatient residential substance use disorder rehabilitation services for clinically appropriate aftercare and continued treatment for his general medical co-morbidity and co-occurring psychiatric disorders.
The health plan's determination is upheld.

The requested health service/treatment of Inpatient substance use disorder rehabilitation services is not medically necessary for this patient.
The inpatient substance abuse rehabilitation treatment, in this case, was amenable to treatment at a lower level of care. The patient was generally motivated and capable of effectively engaging in rehabilitation services in a less restrictive treatment setting with sober supports and/or housing. The patient had completed detoxification treatment and the patient did not need the continued structure or 24-hour monitoring of an inpatient setting in order to safely and effectively participate in rehabilitation substance abuse treatment.

Again, there were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted inpatient level services and treatment. Thus, the inpatient substance use disorder rehabilitation services for the dates in question were not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

This patient is under consideration for bariatric surgery. She was 65.5 inches tall and weighed 324.8 lbs. at the time of the request. This corresponds to a body mass index (BMI) of 53.2 kg/m2. She has comorbid health conditions of hypertension, gastroesophageal reflux disease (GERD), Barrett's esophagus, hyperlipidemia, sleep apnea, and diabetes. At issue is the medical necessity of the RYGB surgery. The surgery was considered not medically necessary on the basis that the patient has not worked with her doctor for at least 6-months in a row sometime in the past 2-years. The patient has attempted weight loss with conventional weight loss programs as are detailed in the mental health evaluation. Unfortunately, she has not been successful with significant sustained weight loss. However, submitted documentation supports that this patient has participated with a supervised diet program. The proposed bariatric operation is medically necessary for this patient at this time as she has successfully completed a multidisciplinary bariatric evaluation, had appropriate dietary counseling over a period of >6-months and has been cleared for bariatric surgery from a mental health standpoint.