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

This patient is 5 feet 7 inches tall, weighs 245 pounds giving a body mass index of 38.4 kg/m2. Weight related co-morbid conditions include: gastroesophageal reflux disease (GERD), sleep apnea. The patient is status/post (s/p) sleeve gastrectomy in 2016. An esophagogastroduodenoscopy (EGD) preformed in late 2018 showed significant dilation of the sleeve, without angulation or hiatal hernia. The patient (Pt) has symptoms despite twice daily (bid) zantac use, switched to bid proton pump inhibitor (PPI) use. Updated dietary and psychological clearance were obtained that did not reveal any obvious barriers to surgery.

The health plan's determination is overturned. The Weight Loss (Bariatric) Surgery with Associated One (1) Day Inpatient Hospital Admission is medically necessary for this patient. This patient has post sleeve gastrectomy GERD a known complication of the procedure. The patient is symptomatic despite medical management. Standard anti-reflux procedures (LINX, laparoscopic Nissen fundoplication) cannot be performed after sleeve gastrectomy since the fundus is removed and the best treatment option is conversion to Roux-en-Y gastric bypass (RYGBP). This procedure is not for weight loss, as any durable significant weight loss after conversion from sleeve to GBP is generally not reported in published studies, but for treatment of GERD in which it is generally curative.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alcohol Detoxification
 
Treatment:  Inpatient Detoxification

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

This is a male patient who was admitted to inpatient substance detoxification treatment in early 2019 for alcohol detoxification treatment.  He had withdrawal symptoms including nausea, sweating, tremors, headache, yawning, irritable mood, anxiety, and sleeping problems and had a Clinical Institute Withdrawal Assessment (CIWA) of 17.  He had prior inpatient substance detoxification and rehabilitation treatments but was still unable to stop his alcohol use.  He was unemployed, homeless and lacked coping skills and the ability to identify relapse triggers.  He was started on a Librium protocol for detoxification treatment during this admission, and he was discharged.  The plan was for substance and alcohol rehabilitation treatment after detoxification was complete. 

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 reasons for inpatient detoxification treatment.  This patient was drinking 10-12 ounces of alcohol per day, and he was at high risk for severe withdrawal symptoms, and even life-threatening withdrawal requiring inpatient substance 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 outpatient detoxification setting, which was evidenced by the fact that he continued to use alcohol despite past inpatient detoxification and rehabilitation treatments.  He required detoxification medication during this admission.  He was at risk for worsened withdrawal symptoms if not in this 24-hour setting, including severe and life-threatening withdrawal symptoms.  He was at risk for worsened withdrawal if he did not complete the five day Librium detoxification treatment in this 24-hour inpatient detoxification. 
Based on the above, the medical necessity for the inpatient detoxification level of care is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nuclear Sclerosis
Treatment: 66984 (Extracapsular Cataract Removal with Insertion of Intraocular Lens Prosthesis (1 stage procedure), Manual or Mechanical Technique (eg, irrigation and aspiration or phacoemulsification) - Eye Surgery - Left Side - 1, 
The insurer denied the (Extracapsular Cataract Removal with Insertion of Intraocular Lens Prosthesis (1 stage procedure), Manual or Mechanical Technique (eg, irrigation and aspiration or phacoemulsification) - Eye Surgery - Left Side - 1. The denial was reversed. 
This is an elderly female patient who had a diagnosis of nuclear sclerosis, suspected glaucoma, possible lupus, asthma, dry eye syndrome in both eyes (OU); status post cataract surgery in the right eye in mid- 2019.  Reportedly, the patient had an imbalance in her vision, and she was unable to perform daily tasks and had dizziness. It was noted that the patient wore glasses to correct the vision in her left eye; however her prescription had recently changed revealing a decrease in her visual acuity. Her medical records showed that her Nuclear sclerotic cataracts were categorized as 2-3+ in both eyes prior to her surgery. The vision is her right eyes post operatively was 20/20 while the left eye remained 20/40. The patient reported that she was experiencing difficulty driving due to the worsening condition in her left eye. 
According to the American Academy of Ophthalmology, (2015), "If cataracts aren't disrupting your life, you can probably wait and have surgery when they really start to bother you," said Ravi D. Goel, M.D., cataract surgeon and a clinical spokesperson for the American Academy of Ophthalmology.  But for those who are feeling impeded by their blurry or dulled vision, the procedure can make a significant beneficial impact...Cataract surgery is only recommended when the outcome is expected to improve vision, unless the cataracts obscure treatments for other eye diseases.  Those considering cataract surgery should discuss how cataracts are affecting their daily lives with an ophthalmologist." 
The carrier's denial of coverage for code 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification) - eye surgery - left side - 1 is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Detoxification
 
Treatment: Inpatient Substance Detoxification

The insurer denied the Inpatient Substance Detoxification. 
The denial was reversed. 

This is a male patient was admitted to inpatient substance detoxification in early 2019 for alcohol detoxification. In early 2019 he reportedly had withdrawal symptoms including increased heart rate and blood pressure with a heart rate of 105 and blood pressure of 138/77. He also had reports of sweats, joint pain, sleeping problems, and anxiety with a CIWA of 7. He reportedly was drinking six 12 ounce beers per day and had past blackouts. He has had past inpatient detoxification a couple of years ago and 2 past treatment episodes without prolonged abstinence. He has depression and anxiety and was taking Zoloft and Zyprexa. He lacked coping skills and needed to better identify triggers. It was reported that he was at risk of losing housing. He was started on a Librium protocol for detoxification. The plan was for inpatient substance rehabilitation treatment, he was discharged a few days after his initial admission. 

The 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 had been drinking alcohol daily and had alcohol withdrawal symptoms. 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 alcohol despite past inpatient detoxification, and he required and needed detoxification medication (Librium) to modify withdrawal and needed 24 hour treatment as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including severe and life threatening withdrawal symptoms.
Patient documentation from admission reported that he was given detoxification medication, Librium, for modification of withdrawal. Further documentation reported that he still had withdrawal symptoms including sweating and anxiety and was responding to the detoxification protocol. It was unlikely that he would have remained abstinent while still having withdrawal symptoms. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required the entire time of hospital stay. 

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

Diagnosis: Left renal colic
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

An acute inpatient level of care was not medically necessary.  Care could have been provided at a lower level of care.  The patient was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis.  Following admission, there were no unstable vital signs reported.  He did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, severe vomiting.  Pain control, IV antibiotics and IVF followed by stent placement in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient has a past medical history (PMH) of diverticulitis and gastroesophageal reflux disease (GERD) who presented to the Emergency Department with complaints of a productive cough, nausea and chest pain for one week. Vital signs notable for tachycardia of 121, T102.1, respirations 24. A physical exam significant for ill appearance and epigastric tenderness. Her lab work was notable for white blood cell count (WBC) 12.07, blood cultures negative, influenza negative. Radiology studies and chest x-ray (CXR) were within normal limits (WNL). A urine culture was without significant growth. The patient was diagnosed with systemic inflammatory response syndrome (SIRS) and treated with fluids and omeprazole. After re-evaluation, the patient was felt to have a viral illness and antibiotics were discontinued. The patient was discharged the following day in stable condition. The health plan denied the inpatient hospital stay as not medically necessary. 

The health plan's determination is upheld. The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the ED c/o fever and productive cough associated with chest pain and nausea. She was hemodynamically stable, had no severe or unstable co-morbidities and the work-up did not demonstrate any cause of her fever. She was discharged with a final diagnosis of viral syndrome. She did not require anti-infectives, did not fail outpatient treatment, there was no evidence of immunosuppression or acute renal failure, and all cultures were negative. While the patient did meet SIRS criteria, she remained hemodynamically stable throughout her stay and improved without antibiotic treatment. Overall, this patient could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Continued inpatient admission 
The proposed treatment, continued inpatient admission was medically necessary for this patient.
The requested benefit of 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 alcohol on a daily continuous basis together with frequent use of cocaine, and daily use of tobacco, and cannabis that did warrant inpatient level detoxification and withdrawal management and monitoring. Detoxification, as indicated, and other treatments pertinent to the substance use disorder 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's social environment was not conducive to an effective detoxification, and the patient struggled initially with withdrawal symptoms in the context of limited insight, impaired judgment and poor control of impulses.
Thus, the adult inpatient stay and detoxification treatment of this patient's substance use disorders did warrant the structure of an inpatient level setting with structure, supports, and 24-hour monitoring. The patients history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments do clearly reflect the seriousness of the substance use disorders, and does support the need for a safe and effective detoxification with withdrawal management as the patient was at high risk for treatment failure or general medical complications such as seizures if detoxification and withdrawal management were to be attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, the American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, and, consistent with New York State instruction for medical necessity reviews including the appropriate application of NY OASAS LOCADTR 3.0 Criteria.
The requested benefit of the continued inpatient admission is clinically appropriate, medically necessary and warranted/necessary for this patient, and is therefore a covered benefit in this case scenario. The substance abuse detoxification for alcohol and continued inpatient level treatment through discharge could not have been safely or effectively provided with lower level services, as noted above. Thus, the requested benefit is not excluded under the plan, and should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM Criteria and NY OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.
Appeal type: Medical necessity
Decision: Overturned

The patient is a female with impacted tooth #20. She presents with a skeletal Class II Division 2 malocclusion and significant crowding. She is treatment planned for orthodontics to address the crowding and to create space to bring the impacted tooth into the arch, but treatment was denied due to lack of medical necessity. The health plan's determination is overturned.

Braces and monthly visits x 4 are medically necessary for this patient. There are two panoramic radiographs, which show a mandibular second bicuspid that is 100% blocked out and impacted. Approximately 10% of all impacted teeth are premolars. Studies have shown almost 65% of untreated impacted teeth will cause some kind of pathology.2  There is no way this tooth will ever erupt without orthodontic intervention to create space for it. If left untreated, the odds of pathology occurring are high.1 Possible pathologies that could occur if this tooth is left untreated include periodontal bone loss, root resorptions of the adjacent teeth, cysts, and tooth decay. This is a medical problem that orthodontics will be able to correct, which is why orthodontics is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anxiety and Depressive Disorder	
 
Treatment: Inpatient Hospitalization

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

This is a male patient who was admitted to inpatient substance detoxification treatment in early 2019. He reportedly had withdrawal symptoms including a Clinical Institute Withdrawal Assessment (CIWA) of 14 and was given Librium and Methadone as well as Clonidine prn for management of withdrawal. He reportedly was drinking two 6 packs of beer per day, using up to $200 of cocaine a few times per week, smoking $75 worth of crack per day, and using 1 stick of benzodiazepine per day a few times per week. He had past detoxification treatments, inpatient in late 2018 and early 2019. He reportedly continued to use even though he was in a Methadone program. He was unemployed, lacked coping skills, and also had depression and anxiety. He took Celexa, Seroquel, and Risperidone. He was put on a Librium protocol and Methadone as well and used Clonidine during this admission to assist in them management of withdrawal. He was discharged with the recommendation for inpatient substance rehabilitation treatment. 

In this case this patient had been drinking alcohol and using multiple other substances including crack, cocaine, and benzodiazepines and had reports of withdrawal symptoms. 
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 alcohol despite past inpatient detoxification treatment. He needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting. He also was at risk for overdose. He reportedly took Librium and Clonidine during this admission for several days. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required the entire time hospitalization as he discharged with the recommendation for inpatient substance rehabilitation treatment. He required inpatient detoxification treatment prior to inpatient substance rehabilitation treatment. He also lacked coping skills and had comorbid psychiatric issues. 

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

The patient received inpatient detoxification related to multiple substance use disorders. The patient was reported to have a history of depression and anxiety and prior treatment with Paxil and gabapentin. Urine drug screen was positive for opiates, cannabis, and buprenorphine. Blood alcohol level was zero. The patient reported using 10 bags of heroin daily for the past five years. Date of last use was the day of admission. 

The health plan's determination is upheld. The inpatient detoxification was not medically necessary for the dates in question. The patient was treated with a methadone taper. Clinical documentation does not describe medical decision-making justifying inpatient treatment for withdrawals as opposed to outpatient treatment or induction onto medication assisted treatment. In addition, the clinical documentation does not establish that there were any severe withdrawal reactions requiring 24 hour care.

There had been no changes in the patient's status that required a higher level of care. The patient did not have withdrawal symptoms requiring 24 hour medical oversight in a hospital setting due to serious and life-threatening complications. The patient did not require 24 hour medical supervision with regular vital sign monitoring. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) tool, the patient did not meet criteria for medically supervised detoxification.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid arthritis
 
Treatment: Olumiant 2 mg OR TABS 

The insurer denied Olumiant 2 mg OR TABS. The denial was reversed.

The patient has a history of RA (Rheumatoid Arthritis), osteoarthritis, sicca syndrome, depression and fibromyalgia. The patient has a history of failed treatment responses to methotrexate, adalimumab (Humira) and entercept (Enbrel). The patient's symptoms improved with Xeljanz XR, sulfasalazine and Medrol combination therapy. However, despite this positive response she reported needing to stop the medications due to chronic sinus infection. The provider attributed the chronic sinus infection to her Xeljanz medication, and recommended an alternative Jak-kinase inhibitor medication, Olumiant. The insurance denied coverage for Olumiant because it was not listed in the insurance formulary, and stated that without trialing and failing on an equivalent medical indication drug, i.e. Kevzara in the formulary, the Olumiant was not medically necessary.  

Baricitinib (i.e. Olumiant) and sarilumab (i.e. Kevzara) are FDA-approved drugs to treat rheumatoid arthritis. Studies have shown both medications are safe and effective for treating moderate to severe rheumatoid arthritis (RA). The patient's rheumatoid arthritis has been very difficult to control. Her symptoms were refractory to first-line treatments with methotrexate, adalimumab and entercept, and have responded to Xeljanz. However, due to its adverse side effect the provider decided to switch the medication to similarly acting medication (Olumiant). While Olumiant and Xeljanz are both Janus kinase (JAK) inhibitors, Xeljanz is a selective JAK1 inhibitor, and Olumiant is a selective JAK2 inhibitor. Olumiant may be able to provide symptomatic relief via similar mechanism of action, without the adverse side effect caused by Xeljanz. 

Considering patient's history of having difficulty in managing her RA, and considering that her symptoms have responded well with JAK inhibitors (i.e. Xeljanz), it is considered medically necessary that she receives another JAK inhibitor to treat and manage her medical condition. 

Based on the above, the medical necessity for Olumiant 2 mg OR TABS is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The proposed treatment was not medically necessary.
This patient presented for evaluation of chest pain. The diagnosis of an acute myocardial infarction (MI) was ruled out by cardiac enzymes, which were negative, and the patient was referred for a coronary angiogram, which revealed no evidence of coronary artery disease. Pulmonary embolism was ruled out by V/Q scan. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at an observational level of care.