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

This is a patient who was admitted shortly after being discharged from another facility for treatment of her opioid use disorder.
She was stated to have an opioid withdrawal symptoms scale score of 8 on admission. She was placed on a methadone taper and had some variation in her opioid withdrawal symptoms scale scores as high as 13.
Her clinical history was significant for an overdose on methadone on. She was reported to be using 15 to 20 bags of heroin intravenously on admission. She was stated to have a draining right upper arm wound that was being treated with antibiotic therapy. She was also using Xanax up to 2 milligrams (mg) per week.
A urine drug screen was positive for benzodiazepines, methadone, and opiates. The patient was not documented as having any severe or life-threatening withdrawal symptoms such as intractable nausea and vomiting, electrolyte abnormalities, or inability to eat. She had a wound that was being treated with antibiotics. Clinical documentation does not establish that his treatment had to take place on an inpatient basis. The health plan's determination is upheld.
The patient did not require immediate hospitalization for a life-threatening medical condition or a severe psychiatric crisis. Withdrawal from opiates is not life-threatening. Clinical documentation does not establish that her arm wound required inpatient care. Opioids were the drug with the most potential to cause harm to self or others. The patient clearly met criteria for an opioid use disorder. The patient was not in full remission from a substance use disorder. The patient was using substances with the risk of medical complications from withdraw. She did not have serious psychiatric or medical symptoms that were required 24 hour inpatient medical management. Her risk of withdrawal was limited to opioids because she was taking only small amounts of benzodiazepines. The patient could have been managed in an outpatient setting through medication treatment.
The patient did not meet criteria for inpatient care. There is no clear documentation establishing that she had unstable medical or psychiatric problems.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
 
Treatment: Continued Inpatient Detoxification Services

The insurer denied the Continued Inpatient Detoxification Services. The denial was reversed.  

This is a male patient who presented to a rehabilitation facility for detoxification. His presenting symptoms include joint and body aches, sweating, anxiety, irritability, and elevated heart rate and blood pressure. The patient reported that he had been using 1 bundle of heroin intravenous (IV) per day as well as cocaine. He has a history of bipolar disorder with a past suicide attempt. He had 2 prior substance treatments resulting in relapse due to his lack the coping skills. He was treated with a Methadone protocol. The patient was discharged home. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. This patient was using a large amount of IV heroin daily and was also using cocaine and was at risk for severe withdrawal, as he had continued withdrawal three day after admission. He could not stop using these substances despite 2 past substance treatments as he lacked coping skills to maintain abstinence. He had a positive toxicology screen for opiates and cocaine and was considered at risk for overdose. He also was at risk for severe withdrawal symptoms due to the large amounts of daily multiple substances of use and he required the entire detoxification protocol of Methadone protocol for 4 days as he was at risk for severe withdrawal symptoms if he stopped the detoxification treatment prematurely. He had active withdrawal symptoms still reported on the day before discharge. 

Based on the above, the medical necessity for the continued inpatient detoxification services at the Medically Supervised Withdrawal Service level of care is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left thoracotomy and Lung Resection

Treatment: Dronabinol 2.5mg OR CAPS 

The insurer denied Dronabinol 2.5mg OR CAPS. The denial was upheld. 

This is a male patient with a history of colorectal cancer, status post left thoracotomy and left upper lingular wedge resection with left lower pneumonectomy and metastasectomy. In mid-2019 the patient was seen for a follow-up evaluation. His physical exam indicated his wounds were healing well. He did have some complaints of continued weight loss and did appear much thinner. His vital signs revealed he was 5 foot 10 inches tall weighing 163 pounds. It was recommended that the patient utilize Marinol for appetite stimulation for two weeks and then follow-up. Further documentation from late 2019 included a discussion with patient that indicated he felt "a little better today" and reported a 10-pound weight gain since starting Marinol 2 weeks prior.

According to the current medical literature, Dronabinol is U.S. Food and Drug Administration (FDA)-approved for the treatment of anorexia associated with weight loss in patients with autoimmune deficiency syndrome (AIDS) and for nausea and vomiting associated with cancer chemotherapy in patients who have failed to respond adequately to conventional antiemetic treatments.  Within the submitted documentation, it does detail that this patient has a diagnosis of cancer and has had previous chemotherapy treatment.  However, it does not appear that the medication is appropriate as there is a lack of documentation supporting that the patient continues with chemotherapy.  The medication is not approved to treat loss of appetite.  The submitted case notes do detail that there are other medications from the patient's preferred drug list for loss of appetite.  Therefore, as there is a lack of current peer-reviewed literature detailing this medication has greater benefit than the patient's preferred drugs.

Based on the above, the medical necessity for Dronabinol 2.5mg OR CAPS is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the hospital with worsening right knee pain and inability to walk. She stated that three weeks ago while she was going to sit on the toilet she heard a loud sound in the leg and experienced a sudden onset right knee pain. She was taken to the emergency department and discharged with orthopedic surgery follow-up. She stated that she was unable to follow up because of severe pain and had been taking nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen. She also reported needing help with activities of daily living.  The patient was seen by orthopedic surgery and ultimately referred for outpatient follow-up, which was consistent with the initial plan when the patient first sustained the injury. The health plan's determination is upheld. The patient was admitted with worsening right knee pain. The plan of care included an orthopedic surgery consult, pain management, ultrasound of the right lower extremity, electrocardiogram (EKG), Haldol, proton pump inhibitor (PPI), and limiting ibuprofen use. Orthopedic surgery saw the patient and recommended no acute surgical intervention and outpatient follow-up. They suspected that it was possible that she dislocated her patella but remarked that her physical examination findings were inconsistent. There was no acute surgical intervention performed during the hospital stay and she primarily received over-the-counter pain medication, physical therapy (PT), and ice. Her care did not meet the level of acuity that is consistent with inpatient management.
Appeal type: Medical necessity
Decision: Overturned

Addiction
Mental Health: Inpatient 

The patient  who presented for inpatient detoxification treatment  in order to address substance use disorder with opioid (heroin and Suboxone) and stimulant (cocaine)in the class substances of abuse. 
The patient has a history of psychiatric disorders with an anxiety disorder including panic attacks and bipolar disorder with the most recent episode of major depression. There was also a past diagnosis of posttraumatic stress disorder (PTSD) and attention deficit hyperactivity disorder (ADHD).The health plan's determination of medical necessity is overturned.
The continued adult inpatient detoxification treatment of this patient's substance use disorders did necessitate the structure of an inpatient level detoxification setting and monitoring, The patients history of substance abuse (frequency and quantity) together with the inability to remain abstinent while in outpatient/medication assisted treatment, lack of a sober recovery environment, and severe psychosocial stressors including high risk behaviors and past legal issues and functional impairments and co-occurring psychiatric disorders do reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management. The patient was at high risk for treatment failure if detoxification and withdrawal management were to be attempted at a lower level of care.
The patient had deficient coping skills, with persistent withdrawal symptoms and with craving that required ongoing management, and clearly this patient could not have completed or sustained a detoxification treatment episode at a lower level of care in this case scenario. Moreover, the patient needed the structure, monitoring and services offered in an inpatient setting in view of the clinical features and treatment dimensions in this case including questionable motivation, high risk for relapse, and lack of a reasonable recovery environment. Therefore, medical necessity is met in this case, consistent with the application of the NY OASAS LOCADTR Tool.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:Substance Abuse
Treatment: Continued inpatient admission 

Summary:
The patient is an adult male. He presented for inpatient detoxification treatment in order to address substance use disorder with opioid (heroin) and stimulant (cocaine) class substances. The patient had relapsed after dropping out of a methadone maintenance treatment program (MMTP) and relapsed, using up to seven bags of heroin daily with IV administration together with $5-10 cocaine (speedball). He self-referred to the emergency department requesting detoxification treatment due to declining function and severe psychosocial stressors within the primary support, social environment, occupational and other psychosocial domains. He denied history of withdrawal seizures or delirium tremens or frequent blackouts. He had past substance use disorder treatment and a recent detoxification treatment episode with immediate relapse.

The requested benefit of the continued inpatient admission could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using large quantities of opioid/heroin with IV administration together with cocaine that did warrant inpatient level detoxification and withdrawal management and monitoring; the continued detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission.  Moreover, the patient presented with moderately severe withdrawal symptoms, and, the patient's social environment was not conducive to detoxification, and the patient struggled with withdrawal symptoms up until the time interval under review in the context of limited insight, impaired judgment and poor control of impulses.

Thus, the requested benefit should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM Criteria and the application of New York State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of obesity hypertension, anxiety, sleep apnea, alcohol use, who went to the hospital with dizziness and dark stool. The hemoglobin was 8.6. The patient was given fluids and intravenous Protonix. The patient was transfused with one unit of red cells. The impression was gastrointestinal bleeding. The blood pressure medicines were held. The patient was kept nothing by mouth and had an endoscopy that showed a large gastric ulcer. There was cauterization. The patient was allowed a diet, had no further bleeding, and went home in stable condition.

The health plan's determination of medical necessity is upheld.The inpatient stay was not medically necessary. The patient had a presentation of upper gastrointestinal bleeding but had no hemodynamic instability, no sustained tachycardia, and no evidence of active ongoing vigorous bleeding. The patient did not require acute care and he was medically stable for a lower-level of care for the dates in question. A definitive endoscopy showing the source for the bleeding was performed with definitive injection of epinephrine and cautery. The endoscopy described the ulcer as non-bleeding. The Milliman care guidelines for acute care were not met on the dates in question. There was no ongoing bleeding, no fresh blood in vomiting or nasogastric aspirate, no evidence of arterial bleeding, clot, malignancy, varices, ulcer size more than 2 cm, portal hypertension, severe liver disease, active comorbid disease, COPD, heart failure, graft placement, aortic aneurysm, coagulation deficits, syncope, perforation, obstruction from ulcer, hemodynamic instability. There was no severe pain, no low platelet count, no inability to tolerate orals, no urgent surgery. Once the patient had the endoscopy, definitive therapeutic endoscopy performed with no evidence of active bleeding, the patient was medically stable for a lower-level of care and did not require acute care for the next two days in order to be observed and to follow the hemoglobin. Throughout the patient's stay, the hemodynamic status remain consistently stable, with no tachycardia, no fever, no hypoxia, no further drop in hemoglobin, and no need for further endoscopy or surgery. In summary, the inpatient stay was not medically necessary at acute hospital level of care based on the clinical information reviewed and the Milliman care guidelines.
Appeal type: Formulary Exception
Decision: Upheld

This is a patient with rheumatoid arthritis (RA). Prior treatments have included: methotrexate (MTX) (ineffective), Orencia (ineffective), Enbrel, Actemra, Plaquenil, Renflexis, Rituxan, Klonopin, Cymbalta, Tramadol, Tylenol, and nonsteroidal anti-inflammatory drugs (NSAIDs) (tried and failed). She is currently on prednisone 10-15 milligrams (mg) daily but is experiencing 'steroid dependency and poor response' per the records. Corticotropin (HP acthar gel) was requested and is being denied by the health plan. The health plan's determination is upheld.

The formulary drug, methylprednisolone, would be as effective as the non-formulary drug, has similar side effects and is widely used to help treat pain, swelling and stiffness in RA, in addition to the appropriate disease modifying immunosuppressive therapy (i.e., a disease modifying anti-rheumatic drug (DMARD) or biologic). HP acthar gel is not widely used in the treatment of RA and its indications are for multiple sclerosis (MS) (acute exacerbations) and infantile spasms. Common side effects include hypertension (HTN), convulsions, infection as well as immunosuppression, adrenal suppression, psychiatric disturbance, hyperglycemia, electrolyte disturbance and osteoporosis. There is no medical reason why the patient cannot try the preferred agent, methylprednisolone, at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major Depressive Disorder and Post-Traumatic Stress Disorder
 
Treatment: Continued Inpatient Admission

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

This is a female patient who was admitted to inpatient mental health treatment due to worsening depressive symptoms which included suicidal ideation, urge to self-harm, sleep and appetite disturbance, hallucination, and feelings of helplessness. The patient was treated with Zoloft, Seroquel, and Remeron. The patient reported improvement in her clinical symptoms from her initial admission.  At the time of her discharge the patient denied suicidal ideations and was using coping skills to manage her symptoms. The patient verbalized improvement with the medication regimen. 

 The APA Practice Guidelines for the Treatment of Patients with Major Depressive Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and that patients with suicidal plan or intent or behaviors, or severe depressive symptoms are candidates for hospitalization. The patient reportedly had improved clinically from her clinical presentation on admission. There were no reports of suicidal or homicidal ideation, intent, plan, or behaviors, inability to adequately care for her basic self-care needs, out of control behavior, self-injurious behavior, severe agitation, psychotic symptoms, or manic episodes. She had reports of depressive symptoms initially, including a suicidal plan and urges to self-harm, but had reports of improvement with the medication regimen. Notes reported that the patient denied suicidal ideation, was using coping skills, had less ruminating, her mood somewhat improved though she still had somewhat dysphoric mood. She had fair sleep and appetite, normal speech, denied hallucinations, denied side effects, and had fair insight and judgment. There were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24 hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting. 

Based on the above, the medical necessity for the continued inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis

Treatment: Inpatient hospital admission

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

This patient is a female with past medical history significant for obesity, chronic lymphedema, and recurrent cellulitis who presented to the emergency department with complaints of chills and erythema of her left ankle area.  

Vitals on presentation included: Temperature 37.3 C, Blood Pressure 101/56, Pulse 94, Respiratory Rate 24, and oxygen saturation at 99%. Laboratory values were notable for the following: WBC-21.5, Hgb-10.3, Hct-35.2, creatinine-1.0, glucose-116.

The patient was admitted for evaluation of left lower leg swelling and pain. She was empirically started on intravenous antibiotics (Ancef then vancomycin). Blood cultures and MRSA screening were negative. The patient remained afebrile, hemodynamically and clinically stable. The patient was discharged to continue oral antibiotics (Keflex and doxycycline) as an outpatient.  

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Constipation
Treatment:  Inpatient Hospital

The patient is a male who was seen in the pediatric emergency department with a chief complaint of abdominal distention caused by a fecal impaction.  He had a long history of constipation with overflow incontinence.  Vital signs on admission were within normal limits, and examination revealed palpable stool in the left upper quadrant and left lower quadrant without signs of acute abdomen.  The suspicion of fecal impaction was confirmed by an abdominal x-ray.  He was given a Fleet enema, and an intravenous (IV) was started.  A nasogastric tube was placed, and he was admitted for treatment consisting of GoLYTELY lavage administered via the nasogastric tube.

The health plan's determination is upheld.

This child presented to the emergency department with a complaint of severe constipation, which was of long duration and for which he was no longer receiving any effective outpatient therapy.  He was in no distress, with normal vital signs and the only finding on examination being palpable stool in the abdomen.  An abdominal X-ray confirmed a distal fecal impaction without evidence of bowel obstruction; the patient was not vomiting, had no abdominal tenderness, and had a normal appetite.  Because the child was receiving no MiraLAX or other therapy, he should not have been assumed to have failed normal outpatient management.  There was no acute condition requiring admission to the hospital.
Effective treatment including disimpaction could have been carried out at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

 Asthma
Inpatient hospital stay

This pediatric patient has with obesity, persistent asthma, allergic rhinitis, and obstructive sleep apnea and presented to the emergency department with wheezing and shortness of breath. Patient was well until 2 days prior to admission when they developed a cough, congestion, and wheezing. The patient had a poor response to albuterol at home at that time and was brought to the primary doctor's office. In the office patient was noted to be febrile with a temperature of 101F, and had biphasic wheezing. Patient received 3 albuterol/Atrovent nebulized treatments as well as oral corticosteroids. However after the treatments the oxygen saturation dropped to 93% on room air, and patient was transferred to the emergency department for further care. In the emergency department patient was noted to be tachycardic and tachypneic. The physical examination was significant for persistent wheezing. Patient received continuous albuterol, magnesium sulfate, and two boluses of normal saline. Laboratory values including a venous blood gas were obtained. A respiratory virus panel was also sent. The symptoms continued despite this treatment, and patient was admitted to the pediatric intensive care unit for acute respiratory failure secondary to status asthmaticus. In the intensive care unit patient was initially treated with albuterol every hour, Atrovent every 6 hours, and corticosteroids. Patient was also receiving maintenance intravenous fluids. The pulmonology team was consulted and recommended starting Symbicort as well as Singulair and cetirizine. The health plan's determination of medical necessity is overturned in whole. The decision making at the time of admission for this patient was consistent with the patient's young age, the presence of status asthmaticus that persisted despite appropriate and intensive treatment, and the need for ongoing intensive treatment with very frequent bronchodilator administration and close monitoring for potential deterioration of clinical status. In the emergency department patient continued to have significant wheeze and abnormal laboratory values. Patient received additional bronchodilators, intravenous fluids, and magnesium sulfate at that time, and the decision was made to admit to the intensive care unit. In the intensive care unit the patient initially required albuterol therapy every hour while also receiving intravenous fluids and continuous cardiorespiratory monitoring. This frequency of therapy requires intensive care in an inpatient setting.