Persius/imr-appeals huggingface dataset:
Diagnosis: Chest pain, shortness of breath
 
Treatment: Inpatient admission, diagnostic testing, medication, monitoring

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

The patient presented to the Emergency Department (ED) with acute onset of chest pressure and diaphoresis. The patient reported right lower extremity cramping and left lower extremity swelling. The patient has a productive cough with green sputum and mild rhinorrhea. The patient has a past medical history of Marfan syndrome, Diabetes Mellitus type II, previous heart attack, status post mechanical aortic valve replacement (AVR), status post left heart catheterization with percutaneous coronary intervention (PCI) and recent admission due to melena and hematochezia. The patient had symptoms of an upper respiratory infection (URI), shortness of breath with intermittent paroxysmal nocturnal dyspnea (PND). The patient states that for the past few days The patient has had sub sternal pressure like chest pain which is similar to when The patient was diagnosed with non-ST elevated myocardial infarction (NSTEMI). The patient states that the pressure radiates to his back but only when The patient is laying down and reports that this is been ongoing for the past month. His vital signs include temperature 36.6 C, heart rate 60, blood pressure 169/80, respirations 18 and oxygen saturation 99% on room air. 

The patient's atypical chest pressure/congestion resolved after receiving intravenous (IV) Lasix. The symptoms were not typical for acute coronary syndrome (ACS). In the hospital The patient did not have any recurrence of significant chest pain and his workup revealed normal troponins and a BNP that was only slightly elevated. His Electrocardiogram (EKG) showed no change from previous recordings and no evidence of acute myocardial injury or ischemia. An echocardiogram and a Computer Tomogram (CT) of the chest did not reveal any significant pathology. 

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.
Diagnosis: Shortness of breath and Chest Pain
Treatment: Inpatient admission
The inpatient admission was not medically necessary. 

This is a female with a history of pulmonary embolism who presented to the ER for further evaluation/management of dyspnea and chest pain. Intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. 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 was also within normal limits with no significant abnormalities noted including no evidence of acute end organ damage. The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where she received therapeutic anticoagulation, supportive care with IV fluids and continued cardiac monitoring. She responded well to the prescribed therapies and was subsequently discharged in stable condition. 

There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the inpatient admission was not medically necessary.
The patient , who requests an increase in personal-care assistant hours from 70 hours a week to 112 hours a week. The patient has a past medical history significant for hyperlipidemia, diabetes mellitus type 2, hypertension, and cognitive dysfunction.  The health plan's determination is upheld.  The requested health service/treatment of personal care assistance increase from 70 hours per week to 112 hours per week is not medically necessary for this patient.  Additional services are not medically necessary. Typically for services to be considered medically necessary the aide must be functioning and performing ADLs and/or IADLs.  It is noted that the patient's ADLs and IADLs can be performed within the allotted time.  Services for monitoring for safety or companion care without the necessity of underlying ADLs or IADLs are not considered medically necessary.  No additional hours are medically necessary.
Diagnosis: Crohn's Disease
 
Treatment: Medication- Humira

The insurer denied treatment with Humira. The denial was upheld.

The patient is a child with long standing constipation, diagnosed with Crohn's disease. His Gastroenterologist is requesting authorization for Humira.  Bloodwork showed a platelet count of 662, albumin 3.0, CRP 67.6, ESR of 53. Patient underwent esophagogastroduodenoscopy (EGD) and colonoscopy. Pathology report demonstrates chronic ileitis with granuloma, colitis. Patient was started on steroids, which improved many of his symptoms. Plain x-ray shows constipation. Recent emerging data has demonstrated disproportionate risks of hepatosplenic T-cell lymphoma among adolescent males exposed to immunomodulators.
Diagnosis: SOB; Wheezing
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient had asthma exacerbation with failed outpatient therapy, emergency room therapy. The patient had history of similar asthma exacerbations in the past with requiring mechanical ventilation. Since the patient failed outpatient as well as emergency room treatment and had significant anxiety symptoms during early hospitalization stay, the acute in hospital level of care was medically necessary.
Diagnosis: Diabetes type II, status post mechanical fall
Treatment: Inpatient admission
The inpatient admission as not medically necessary.

The patient is a female with past medical history of schizophrenia and type II DM (diabetes mellitus). She was seen at the emergency room, after a trip and fall with laceration to the forehead.  She denied headache, abdominal pain, neck pain, back pain, numbness, weakness, and vision changes. 

The patient's vitals were as follows: BP (blood pressure) 104/71; P (pulse) 95; RR (respiration rate) 16; Temp 36.6C; SpO2 (pulse oximetry) 95% on room air.  On physical examination, there was a 1.0 cm subcutaneous linear shaped, injury to the right forehead.  No neurology exam, motor strength was 5/5, sensation intact, cranial nerves intact; normal gait.  She was awake, alert and oriented times three.  She had mild tenderness in the right knee.  

The patient's laboratory studies revealed the following: urinalysis was unremarkable; hemoglobin was 12.2, hematocrit 36.3, platelet 206, WBC (white blood count) 8.7, potassium 3.7, sodium 143, and creatinine 0.7.  CT of the cervical spine and head demonstrated no evidence of acute pathology.  Chest x-ray showed no evidence of acute cardiopulmonary disease.  EKG (electrocardiogram) showed normal sinus rhythm (NSR) at 70 bpm.  Right knee x-ray revealed mildly comminuted vertically oriented fracture of the mid to lateral patella with minimal displacement; moderate suprapatellar effusion.  Impression included unspecified fall, and vertical patellar fracture. 

Medical records noted that the patient lives alone, with no home care; She has had two falls in a week and ambulates with unsteady gait in the emergency room.  It was noted that patient has poor insight, poor historian and unable to care for herself, will require admission for placement.  Management included placement in knee immobilizer, Weight bearing as tolerated, RLE (right lower extremity) elevation; it was recommended that she follow with outpatient orthopedics.  While on admission, she was seen by physical therapy. 

On the day of discharge, the patient was medically stable for discharge home.   It was noted that she will receive home care. 

The patient was admitted to the hospital following a fall, and was diagnosed with patellar fracture, and mild laceration of the forehead.  Recommended treatment was conservative as well as outpatient follow-up by orthopedic specialty.  She was hemodynamically stable when she presented to the emergency department.  There was no evidence of altered mental status, confusion, respiratory compromise, significant persistent life-threatening arrhythmias, or sepsis.  There were no serious neurologic abnormalities like brain infection, cerebral bleeding/ischemia, increased intracranial pressure or spinal cord injury.  CAT scan of the brain did not show any acute bleed or hemorrhage.  

In view of the foregoing, the inpatient admission was not medically necessary, because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.
Varicose veins
Surgical services

The patient presented with right leg symptomatic varicose veins. Main symptoms include burning, aching and throbbing. The patient has attempted and failed conservative therapy with graded compression stockings for several months' duration. The symptoms are lifestyle limiting and interfere with  activities of daily living. A duplex scan demonstrates reflux in the right accessory great saphenous vein. The health plan's determination of medical necessity is overturned in whole. Endovenous ablation of the right accessory great saphenous vein for this patient is the current standard of care treatment for symptomatic varicose veins and saphenous vein reflux. The most recent consensus guidelines for the Society for Vascular Surgery and the American Venous Forum support endovenous thermal ablation for this patient based on her clinical presentation. Endovenous ablation is supported by the peer reviewed literature including level 1 randomized evidence. Several current peer reviewed papers support the use of endovenous thermal ablation for patients with symptomatic varicose veins with excellent results. Hamann and colleagues demonstrated excellent results with thermal ablation (radiofrequency and laser) in patients with symptomatic varicose veins. They wrote that the current treatment strategy for many patients with varicose veins is endovenous thermal ablation. The most common forms of this are endovenous laser ablation (EVLA) and radiofrequency ablation (RFA). However, at present there is no clear consensus on which of these treatments is superior. The objective of this study was to compare EVLA with two forms of RFA: direct RFA (dRFA; radiofrequency-induced thermotherapy) and indirect RFA (iRFA; VNUS ClosureFast). Patients with symptomatic great saphenous vein (GSV) incompetence were randomized to receive EVLA, dRFA or iRFA. Patients were followed up at 2 weeks, 6 and 12 months. The primary outcome was GSV occlusion rate. Secondary outcomes included Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ) score and adverse events. Some 450 patients received the allocated treatment (EVLA, 148; dRFA, 152; iRFA, 150). The intention-to-treat analysis showed occlusion rates of 750 (95 per cent c.i. 680 to 820), 599 (521 to 677) and 813 (751 to 876) per cent respectively after 1 year.
This is a patient with a history of substance use disorder who presented  with a request for detoxification services after relapsing. The patient was using heroin with up to 5 bags with intranasal administration on a continuous daily basis together with use of a prescribed benzodiazepine. She has a history of a mental disorder best characterized as schizophrenia treated with quetiapine, and major depressive disorder. She has a history of psychiatric hospitalizations. The health plan's determination of medical necessity is upheld.
The continued treatment could have been safely and effectively provided at a lower level of care. The acute inpatient treatment of this patient's substance use disorder did not require the continued structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of schizophrenia and ongoing substance use disorder with heroin and a prescribed benzodiazepine. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or acute symptoms of psychosis, or perceptual disturbance that would have warranted inpatient level treatment for the time interval under review. There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had no complications that required continued withdrawal management or general medical services, as noted in the clinical summary. The patient had fair insight and control of impulses and was cooperative and generally motivated to continue with substance use disorder treatment.
Diagnosis: Pneumonia and sepsis

Treatment: Inpatient admission

The insurer has denied Inpatient admission. The denial was reversed.

This patient is a male who was admitted to the inpatient medical hospital as he had pneumonia and sepsis and was also getting methadone for heroin detoxification. He also had alcohol and cocaine use. He had requested heroin detoxification. Medical issues included worsened shortness of breath, cough, sputum production with yellow phlegm, and dyspnea on exertion. He had recent pneumonia as well and was noncompliant with antibiotics. His CT revealed reticular infiltrates and he had a 20-lb. weight loss in 3 months. He also received IV antibiotics but signed out AMA.

The insurer denied coverage for inpatient medical hospital treatment as not medically necessary treatment. They stated that he had no hemodynamic, pulmonary, neurological, or metabolic reason for hospitalization, and they recommended a less restrictive level of care. 

Chart notes provided enough specific evidence to support the patient required 24-hour hospital treatment during the period in question. The American Psychiatric Association Practice Guidelines for the Treatment of Patients with Substance Use Disorders indicate those patients who exhibit failure to achieve abstinence or patients who relapse frequently, or fail to be cooperative with or benefit from outpatient detoxification; currently abuse other substances, very heavy use or tolerance, putting one at high risk for complicated withdrawal; are candidates for inpatient detoxification treatment. 

In this case, this patient had serious medical problems, including pneumonia and sepsis. He had methadone for heroin detoxification and had been drinking alcohol and using cocaine. He had worsened shortness of breath, cough, sputum production with yellow phlegm, and dyspnea on exertion. He had recent pneumonia, as well and was non-compliant with antibiotics. His CT revealed reticular infiltrates and he had a 20-lb. weight loss in three months. He also received intravenous (IV) antibiotics, so he could not safely and effectively be treated for heroin detoxification in an outpatient setting. He required 24-hour medical hospital treatment then. 

According to the LOCADTR, he did require 24-hour treatment as he could not safely and effectively be treated in outpatient detoxification settings, as he continued to use heroin, alcohol, and cocaine, despite multiple serious medical issues, and he required and needed methadone for heroin detoxification. He was at risk for worsened withdrawal symptoms if not in this 24-hour setting; including severe withdrawal symptoms. He had serious medical issues complicating treatment for heroin detoxification. Inpatient medical hospital treatment was medically necessary. The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is substantiated.  The insurer's denial is reversed.
Diagnosis: Sickle cell crisis
 
Treatment: Inpatient admission, medication, monitoring

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

This case involves a male who was brought to the hospital by ambulance with a complaint of pain in his low back, knees, hip, and chest. He complained of sickle cell crisis at presentation.  The patient had no cardiac history and was compliant with his medications. He was alert and oriented; he had no shortness of breath, no loss of consciousness, and lung sounds were clear and equal.  The abdomen was flat and soft.  The patient had no rigidity.  His pain was rated 10/10, blood pressure was 117/73, respiratory rate was 18, pulse rate was 90 and oxygen saturation was 100%.  Upon reevaluation, the patient's blood pressure was 93/55 and oxygen saturation on room air was 94%.  The patient was admitted for sickle cell crisis.  This was the patient's usual sickle cell crisis presentation. He had 2 rounds of pain medication and stated he still had his crisis pain. The patient underwent a chest x-ray which was normal.  The EKG showed normal sinus rhythm.  He refused intravenous fluids.  The patient was treated with pain medications. His pain improved and he was discharged.

MCG indicates that admission for sickle cell may be appropriate for patients who have acute pulmonary symptoms, hypoxemia or acidosis, and altered mental status, respiratory treatments needed that can only be performed in an acute inpatient setting, or pain insufficiently responsive to observation care that requires treatment in inpatient setting, such as parenteral opioids.  The patient did not have hypoxemia or an altered mental status. He responded to pain medications. The records failed to support the patient could not have been treated at a lower level of care, such as observation.  The patient was not noted to have failed observation care.    

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Diagnosis: Septicemia

Treatment: Inpatient Admission

The insurer denied Inpatient Admission. The denial was reversed. 

This is a middle aged patient who was referred to the emergency department (ED) from a nursing home. He presented with complaints of fever, anemia, and left foot ulcer. The patient was started empirically on intravenous antibiotics (Vancomycin and Zosyn) for a chronic left foot infection/foot ulcer; a foul smelling discharge was noted from his left extremity. In addition, the patient required hemodialysis. An x-ray of the foot showed diffuse tissue swelling; an osteomyelitis could not be ruled out. A chest x-ray revealed moderate bilateral pleural effusions with underlying atelectasis or infiltrate.

According to the documentation, the patient was referred to the hospital from nursing home after developing fever (100.4 F) at hemodialysis and was noted to have severe anemia. The patient had numerous laboratory abnormalities including leukocytosis (WBC 16.4), anemia (Hgb 7.3), chest x-ray findings, as well as a chronic left foot infection. He required hemodialysis and had co-morbid risk factors.

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is substantiated. The insurer's denial is reversed.
Diagnosis: Seizure Disorder

Treatment: Inpatient Admission

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

This is a middle age male who presented to the Emergency Department in early 2019 by Emergency Medical Services for a syncopal episode.  Per the patient's wife, the patient was out of consciousness until Emergency Medical Services arrived for approximately 10 minutes later. The patient complained of a headache upon arrival, however, he denied chest pain, shortness of breath, and palpitations. It was noted that Cardiopulmonary resuscitation was performed by bystanders at the scene. His physical examination revealed the patient was awake and oriented x 3. The patient had no focal deficits and had a normal motor and sensory examination. He had an EKG which was normal and a computerized tomography scan of his head which was unremarkable; no intracerebral hemorrhage or contusion was identified. The patient was consulted by neurology for questionable seizure activity. The patient was discharged on Keppra after neurology confirmed the patient was stable. He was instructed to follow-up in one week.  

MCG indicate that admission may be appropriate for patients who have a new onset severe neurologic finding requiring inpatient care, a neurological trauma requiring inpatient treatment, or for a neurologic condition, symptoms, or finding for which emergency and observation have failed or are not considered appropriate. Additionally, admission for seizure would be appropriate for patients who had status epilepticus or repetitive seizures not controlled with emergent treatment, brain disorder, cardiac arrhythmia of immediate concern, altered mental status that is severe or persistent, a new focal neurologic deficit, or for a recurrent seizure. The records supported that the patient had a syncopal episode, rule out seizure. The patient was admitted with the diagnosis of seizure. At the time of admission, the patient did not have focal deficits and had not failed Emergency Department care. The records failed to support that the patient had hemodynamic instability, status epilepticus, repetitive seizures or recurrent seizures.  The records failed to support that the patient could not have been placed at a lower level of care, such as observation.

Based on the above, the medical necessity for the inpatient admission to is not substantiated. The insurer's denial is upheld.
Diagnosis: Possible Sepsis/Pneumonia/Bronchitis

Treatment: Inpatient admission

The insurer denied inpatient admission. The denial was upheld.

This is a female who presented to the Emergency Department (ED) with complaints of fever, chills, muscle aches and pains, along with some blood streaked yellow sputum.  The patient has a past medical history of diabetes mellitus, hypertension, hernia repair, status post Cesarean section and myomectomy.

At presentation to the ED, vital signs included a temperature of 101F, a heart rate of 105, a respiratory rate of 20, and a blood pressure of 144/90 mm Hg.  Oxygen saturation on room air was 99%.  The patient was awake and alert.  Head, ears, eyes, nose, and throat (HEENT) exam was within normal limits.  Lungs were clear.  Cardiovascular system (CVS) S1 S2 was normal.  The abdomen was soft and non-tender.  The patient was alert and oriented x3. The white blood cell (WBC) count was 5.18K, the hemoglobin was 12.3 and electrolytes were within normal limits. The blood urea nitrogen (BUN)/Creatinine was 12/0.7 respectively. A respiratory syncytial virus (RSV) panel was negative, as was influenza.  The lactate was 1.4, the procalcitonin level was 0.15 and the urinalysis (UA) was negative. A chest x-ray had no acute infiltrate noted.

The patient was empirically started on broad spectrum antibiotics - Vancomycin/Cefepime for possible Sepsis/Pneumonia/Bronchitis.  The patient remained stable after presentation.  As per the history & physical, the patient was in no acute distress.  She was hemodynamically stable and not hypoxic.  Lungs were clear.  The WBC count was normal.  The chest x-ray was negative.  The patient's fever came down.  She remained afebrile and hemodynamically stable with oxygen saturations of 96-99% on room air.  The patient was subsequently switched to Rocephin and Azithromycin.

The patient remained stable after admission.  An additional WBC count was normal at 4.4K.  Blood and urine culture & sensitivity were negative.  There were no signs of sepsis.  The patient did not need acute hospitalization.  She could have been placed under observation status while diagnostic testing and treatment were initiated.  The patient was tolerating oral intake and could have been switched to oral antibiotics and discharged home with close follow-up in an outpatient setting.  The patient had bronchitis and no evidence of pneumonia radiologically.  The WBC count was normal.  The patient was not hypoxic.  The CURB 65 score was Zero.  

The prior denial is upheld. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

Based on the above, the medical necessity for the inpatient admission for acute level of care is not substantiated.  The insurer's denial is upheld.