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

Diagnosis: Worsening depression
Treatment: Inpatient admission

The Inpatient admission was medically necessary for this patient.

The patient required the admission and the continued acute inpatient level care and the structure and monitoring of an acute inpatient level setting in order to remain safe and to administer treatment for his psychiatric disturbance and co-occurring substance use disorders while conducting an evaluation, and while observing his functioning with the resumption/adjustment of clinically appropriate medications. The clinical course was complicated by severe substance use disorders and psychosocial stress being addressed during the time interval under review. Additionally, the treatment team was planning for a safe and clinically appropriate disposition with aftercare arrangements.

The medical necessity for the requested inpatient level structure and monitoring is reasonable, and in the patient's best interest in view of the patient's severe symptoms of mood disorder, risk for suicide, and co-occurring substance use disorders. In view of these clinical features and the complicated presentation with suicidal ideation with a plan, the patient's continued active treatment with safety monitoring was warranted in the context of the patient's deteriorated functioning and severe psychosocial stressors involving housing, occupational, social and economic domains. Additionally, the inpatient stay was medically necessary in order to monitor the response to medications, to insure that the patient will have a sustained response to treatment, and to continue to address the acute risk of suicidal behavior in the context of severe symptoms of bipolar mood disorder and severe psychosocial stressors in a patient with impaired judgment and poor control of impulses. The necessity for continued inpatient level services reflects sound medical judgment in keeping with prevailing standards of professional practice, and with the published practice guidelines and criteria, referenced below, as well as New York State instruction for medical necessity reviews including the appropriate application of NY State OASAS LOCADTR 3.0 Criteria, referenced below.

The patient's presentation and clinical features included severe symptoms of mood disorder, suicidal risk, substance use disorder, and deterioration in functioning with inability to care for self in the context of multiple comorbid conditions related to her relapse and non-compliance with outpatient treatments. The patient remained at risk for relapse during the time interval under review thru discharge. Additionally, a safe and clinically appropriate discharge plan and disposition was critical in this case to prevent re-hospitalization or immediate relapse or a suicide attempt. The patient could not have been expected to participate in treatment at a lower level of care in this case scenario.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance abuse

Treatment:  Inpatient Admission

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

This is a male patient with a history of inpatient substance detoxification treatments.  He reported having decades of drug use that included inhaling heroin and cocaine, and smoking cannabis.  He presented to a treatment facility for substance detoxification treatment.  His withdrawal symptoms included tremors, nausea, vomiting, joint pain, urges, irritable mood, sleeping problems, and anxiety.  He had a Clinical Opiate Withdrawal Scale (COWS) score of 12.  He tested positive for opiates, cocaine, and tetrahydrocannabinol (THC).  He received methadone for detoxification.  He left the treatment facility against medical advice after 2 days treatment.

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 was the case with this patient.  This patient had multiple serious substances of use in large amounts with a long history of use and was considered at risk for overdose.  He also was at risk for severe withdrawal symptoms due to the large amount of heroin use; therefore, he required a 24-hour inpatient hospital detoxification treatment.  According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR,) he did require 24-hour treatment, as he could not safely and effectively be treated in less restrictive settings.  This was due to the fact that he continued to use multiple serious substances despite past inpatient detoxification treatments.  Also, he required and needed detoxification medication (methadone) to modify withdrawal and prevent severe withdrawal.  He also did not have enough sober supports, as he was homeless.  

The health plan did not act reasonably, or with sound medical judgment, or in the patient's best interest. 

The carrier's denial of coverage for inpatient substance abuse is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Inferolateral ischemia
 
Treatment:  Inpatient Admission

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

This is a male patient with a medical history of hypertension, hyperlipidemia, carotid artery disease with a stroke, persistent right-sided weakness, and a percutaneous coronary intervention (PCI).  It was reported that he had been experiencing left-sided chest tightness, dyspnea and fatigue while walking for several months.  Several diagnostic tests were performed.  An echocardiogram that showed anterolateral hypokinesis, a dilated left ventricle, and a left ventricular ejection fraction (LVEF) of 45-50%, and a Lexiscan stress test that showed mild anterior and mild to moderate inferolateral ischemia with a LVEF of 37%.  A scheduled coronary angiography with percutaneous coronary intervention was performed without complication.  The procedure revealed 70-80%proximal left anterior descending (LAD) disease with a patent stent, treated with balloon angioplasty and a drug eluting stent, as well as 70-80% tandem proximal left circumflex lesions, also treated with balloon angioplasty and drug eluting stents.  The dominant right coronary artery was completely occluded and left to right collaterals.  He was medically stable and discharged home with outpatient follow up instructions. 

There is no evidence that this patient required an acute inpatient level of care for monitoring following percutaneous coronary intervention.  This could have been completed at a same-day procedure level of care.  The healthcare plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

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

The patient is a female with Class II malocclusion. The patient has mild maxillary crowding and mild mandibular spacing. The patient has a mild open bite and mild overjet. The proposed treatment is braces. The subject to be determined is the medical necessity for braces and follow-up visits. 

The health plan's determination is upheld. 

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score an 11 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, severe traumatic deviation, impacted permanent anteriors where extraction is not indicated, deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 millimeter (mm) or greater and underbite 3.5mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, braces and follow-up visits are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/ Circulatory Problems - Chest Pain
Inpatient Hospital

The patient is a female with a history of hyperlipidemia. Cardiac catheterization performed in a year prior showed nonobstructive coronary artery disease. She presented to the emergency department complaining of two days of left-sided chest pain and dyspnea. Her blood pressure was 135/85 millimeters of mercury (mmHg) with a heart rate of 105 beats/minute. Her respiratory rate was 19/minute with a room air oxygen saturation of 100%. Her cardiac exam was unremarkable. An electrocardiogram showed sinus tachycardia at 106 beats/minute and was otherwise normal. Chest x-ray was normal. Chest computed tomography (CT) angiogram showed no evidence of aortic dissection. Her serum troponin level was normal. Her serum potassium was markedly low at 1.6 millimoles per liter (mmol/L) and increased to 4.2 after potassium supplementation. She was treated with aspirin, nitroglycerin and ketorolac and admitted to the hospital to rule out acute coronary syndrome. Repeat troponin levels and electrocardiograms were normal. The patient was discharged. Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld.

An inpatient level of care was not medically necessary. This woman presented with atypical symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. On the other hand, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. Her HEART score was 2, indicating a low risk for major adverse cardiac events. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care status. This approach has been shown to be both safe and is in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

This case describes a female patient who sustained a slip and fall on some stairs in her home resulting in pain and deformity. Evaluation in the Emergency Department revealed displaced left tibia and fibula fractures.  The patient underwent surgery for placement of an intra-medullary nail on. The patient was able to ambulate with crutches and was deemed stable for discharge to home the following day. At issue in this case is the medial necessity of the inpatient hospital stay for this patient.

The health plan's determination is upheld.

The inpatient stay was not medically necessary for this patient. 
The provided medical records document that this patient with no significant medical history underwent placement of an intra-medullary nail for a displaced left tibial shaft fracture. She was gait trained with crutches and had adequate pain control on post-operative day #1. She was deemed stable for discharge home. The care rendered in this case is consistent with the current, peer-reviewed orthopedic literature as documented by Vallier and colleagues in the Journal of Orthopedic Trauma and by Hu and associates in the Journal of Orthopedic Surgery and Research.
This episode of care could have been completed under a lower level of care status and there is no documentation in the provided medical records to justify the inpatient hospital admission in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain 
Issue under review: Inpatient admission 

Determination: The inpatient admission was medically necessary. 

The patient is an adult male with a past medical history significant for HTN (hypertension), dyslipidemia, CAD (coronary artery disease), h/o (history of) MI (myocardial infarction), CHF (congestive heart failure) with reduced EF (ejection fraction) of 20-25%, s/p (status post) AICD (automatic implantable cardioverter defibrillator) placement, alcohol, tobacco and cocaine abuse. He presented to the ER with complaints of new onset chest pain of one day duration, rated 6-8/10 in severity, radiating to the left arm, associated with exertional dyspnea. Patient admitted to non-compliance with the medical regimen, as well as to recent cocaine abuse. 

The patient had tachycardia and tachypnea on admission, with elevated BP (blood pressure). ECG (electrocardiogram) revealed normal sinus rhythm with non-specific ST-T changes. Cardiac troponin was mildly elevated. The patient was treated with calcium blockers, antiplatelet therapy, nitrates, Lasix and statin.  B-blocker was held due to recent cocaine use. 

The patient was admitted to telemetry due to suspected ACS (acute coronary syndrome). Serial troponins were checked and were persistently mildly elevated. Telemetry revealed episodes of non-sustained ventricular tachycardia. AICD interrogation was performed, revealing episodes of SVT (supraventricular tachycardia) with heart rate over 200. The patient was treated with medical therapy for CAD, CHF and SVT. His beta-blocker was restarted with monitoring of BP. He was seen in consultation by cardiology service, his troponin elevation was felt to be secondary to CHF and cocaine use, and no catheterization was planned. Outpatient follow-up with cardiology and EP (electrophysiology) was recommended. The patient was discharged home the following day. 

The patient presented with new onset chest pain, suggestive of unstable angina in the setting of recent cocaine abuse. The patient had a complex cardiac history, including severe systolic CHF, AICD, arrhythmia, CAD, prior MI. His cardiac troponin was elevated, suggestive of myocardial injury.  His medical therapy was complicated by cocaine use and potential interaction with beta-blockers. Ventricular and supraventricular tachycardia were detected and medical therapy was adjusted. Given the presentation, clinical suspicion for an acute coronary syndrome/unstable angina, elevated troponin, and multiple risk factors, he would not be an appropriate candidate for an ED chest pain observation unit. It would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient hospital

The patient has hyperlipidemia and hypertension who presented to an Urgent Care Center with a one-day history of right lower quadrant abdominal pain and one episode of vomiting. The white blood cell count was 12 and a computed tomography (CT) scan was completed which showed non-perforated appendicitis. The patient was transferred to a hospital. The patient was started on Zosyn, and consented for an emergency laparoscopic appendectomy. An uncomplicated procedure was performed. Post-operative care was also uncomplicated. In the post-anesthesia care unit, a plan to discharge to home was noted. The health plan's determination is upheld in whole. The patient by CT had a non-perforated appendicitis. An uncomplicated procedure was performed. This was an uncomplicated appendectomy that was efficiently and effectively managed by the hospital in the period of 5 hours. 

The post-operative care was also uncomplicated, and a plan to discharge the patient to home was noted the same day. This type of uncomplicated procedure is an ambulatory/ outpatient procedure. This patient could have been treated at a lower level of care. Inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depressive symptoms: suicidal ideation and plan 

Treatment: Inpatient psychiatric hospitalization

The insurer denied coverage for continued inpatient psychiatric hospitalization. The denial is upheld. 

This patient is a female who was admitted to this inpatient mental health treatment in this hospital due to worsened depressive symptoms including suicidal ideation and plan, depressed mood, feelings of hopelessness and helplessness, anhedonia, isolation, agitation, poor activities of daily living and impaired insight and judgment. She was smoking cannabis a few times per week. She had impairment in functioning and was unable to work or attend college. She had nightmares and anxiety. She had diagnoses of Post-Traumatic Stress Disorder (PTSD), Panic Disorder and Generalized Anxiety Disorder. She took Seroquel and Buspirone. She improved and was discharged. The insurer denied coverage for continued inpatient mental health treatment in this hospital.

This reviewer agrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital. The chart notes did not provide enough specific evidence to support that she still required 24-hour psychiatric hospital treatment then or that she could not be treated in a less restrictive level of care then. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicidal intent or plan or attempts are in need of inpatient treatment. It also reports that patients with feelings of hopelessness are at increased risk for suicide. This patient had suicidal ideation with a plan and worsened depressive symptoms, including feelings of hopelessness on admission and required and received psychiatric hospital treatment. However, as of a specified date the chart notes did not report further suicidal ideation or plan or feelings of hopelessness.

As of a specified date there were no reports of suicidal ideation, plan, or intent, self-injurious behavior, psychotic symptoms, aggressive, threatening, or severely agitated behavior, manic episodes, homicidal thoughts, severe depression with inability to adequately care for her basic needs, feelings of hopelessness, acute medical instability or withdrawal symptoms. Also, as of that date there was no specific documentation to support that she was considered an imminent danger to self or others or in need of 24-hour acute psychiatric hospitalization. Furthermore, as of a date specified 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. 

 As a result, uphold the previous decision and deny coverage for inpatient mental health treatment at this hospital. The health care plan acted reasonably and with sound medical judgment and in the best interests of the patient.

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

Diagnosis: Hypertension, weakness, nausea
Issue under review: Inpatient admission

Determination: The inpatient admission was not medically necessary.

The patient is an adult female.  She has a history of asthma, hypertension, and tobacco abuse.  She presented with generalized weakness, nausea, abdominal pain, and elevated blood pressures.  She had not taken her antihypertensive agents on the day of admission.  

The patient's laboratory indices were notable for a creatinine 1.1 and potassium 4.2.  The electrocardiogram showed sinus bradycardia.  The patient was afebrile with blood pressure 196/96 and pulse 50.  Cardiac enzymes were negative.  The patient was monitored on telemetry and intravenous fluids and oral antihypertensive agents were restarted.  The antihypertensive regimen was adjusted, with hydrochlorothiazide and metoprolol being added, with improvement in the blood pressure.  

The patient had elevated blood pressures, but she did not have evidence of hypertensive emergency or malignant hypertension.  There was no evidence of end organ damage related to elevated blood pressures, such as acute cerebrovascular accident, acute heart failure, seizure activity, acute kidney injury, hypertensive encephalopathy, or acute coronary syndrome.  Intravenous antihypertensive agents were not required; the blood pressure improved with reinitiation of patient's oral antihypertensive regimen.  The patient's bradycardia was mild, and pacemaker placement was not required.  Laboratory indices were essentially unremarkable.  The patient did not have syncope or alteration in mentation.  

In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: PTSD; Depression
Issue under review: Ketamine

Determination:
The health plan should cover the Ketamine.

The patient is an adult male. He has a diagnosis of treatment-resistant depression. He has been undergoing ketamine treatment. He reports, "The ketamine infusion has dramatically improved my condition and quality of life."

The patient's treating physician wrote that he first saw the patient for posttraumatic stress disorder manifesting as severe treatment resistant depression, generalized anxiety, anhedonia, obsessive compulsive behaviors, and isolation. He notes that after six ketamine infusions, the patient had dramatic improvement in all symptoms. The patient's primary care physician wrote that the patient had failed a trial of Wellbutrin, but was responding well to ketamine therapy.

In a "Consensus Statement on the use of Ketamine in the Treatment of Mood Disorders" from the American Psychiatric Association (APA), Sanacora and associates (2017) noted that several studies provided evidence of ketamine hydrochloride's ability to produce rapid and robust anti-depressant effects in patients with mood and anxiety disorders that were previously resistant to treatment. Although there are to date insufficient large studies showing a consistent response, there are enough studies indicating immediate and dramatic responses in some patients to warrant a trial of this medication in patients suffering from treatment-resistant depression.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: PTSD; Depression
Issue under review: Ketamine

Determination:
The health plan should cover the Ketamine.

The patient is an adult male with PTSD (posttraumatic stress disorder) and depression who has been prescribed Ketamine infusions. 

The patient has been unresponsive to treatment per the attached documentation. In patients who have failed conventional treatments (cognitive therapy, medications) and continue to decompensate, more aggressive methods are sometimes required.  Other options include ECT (electroconvulsive therapy), which is quite invasive and with mixed results in the literature, and ketamine infusions.  Ketamine infusions have been shown to be effective for the treatment of refractory depression, even with comorbid diagnosis such as PTSD, in random controlled trials (RCT).  

This is not a new treatment, previous RCTs date back to 2013 on the topic.  Given the risk of untreated depression, and that the patient has been refractory to other treatment methods, specifically noted Wellbutrin, the requested ketamine infusions are medically appropriate and supported in the literature.