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

Diagnosis: Acute Appendicitis
 
Treatment: Inpatient Admission

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

This patient is a young female who presented to the emergency department (ED) in early 2019 for right sided abdominal pain and four episodes of diarrhea. She has a history of hypothyroidism. Her physical exam was significant for right lower quadrant and right upper quadrant tenderness. She was afebrile with stable vital signs. An abdominal ultrasound revealed acute appendicitis. She was maintained nothing by mouth (NPO) started on intravenous (IV) fluid and antibiotics (IVAB) and prepared for surgery. The patient underwent an uneventful laparoscopic appendectomy for non-perforated acute appendicitis. She was monitored in the Post Anesthesia Care Unit (PACU) and then discharged home after a period of stability.  

As per Milliman Care Guideline (MCG)- Health Inpatient and Surgical Care 23rd Edition Appendectomy, uncomplicated, open or laparoscopic ORG: P-20 (ISC) the Operative Status Criteria is ambulatory for most children with acute, uncomplicated, non-perforated appendicitis and those undergoing interval appendectomy after non-operative treatment. It is inpatient for children with complicated appendicitis (e.g. perforated without generalized peritonitis) or for those requiring prolonged (e.g., more than 24 hours postoperatively) care after surgery (e.g., co morbid illness). The goal length of stay is ambulatory or 1 day postoperative. Extended Stay as defined by Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days) may be needed for: Prolonged fever and prolonged fever may require longer observation in hospital on parenteral antibiotics and one can expect brief stay extension; Complicated appendicitis with discovery or development of generalized peritonitis or intra-abdominal abscess may require longer observation on parenteral antibiotics; Complications such as wound infection, intra-abdominal abscess, fecal fistula, pylephlebitis, and intestinal obstruction may occur and require continued observation or reoperation or postoperative bleeding may require reoperation and one can expect brief to moderate stay extension; Prolonged ileus with prolonged ileus may delay initiation of feeding and one can expect brief stay extension.  None of these situations were seen in this case as the patient had an uncomplicated non-perforated appendicitis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Issue under review: Inpatient detoxification

Determination:
The Inpatient detoxification was medically necessary.

The requested benefit of Continued Inpatient detoxification 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 intermittent use of cocaine and cannabis, and daily use of tobacco that did warrant inpatient level detoxification and withdrawal management and monitoring. Detoxification, as necessary, 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 struggled initially with withdrawal symptoms in the context of limited insight, impaired judgment and poor control of impulses, and was continued on Librium and PRN medications during the time frame under review.

Thus, the detoxification treatment of this patient's substance use disorders did warrant the continued 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 history of frequent relapses did 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 have been attempted/continued at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, 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/Guidelines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
 
Treatment: Inpatient substance detoxification admission, medication, monitoring

The insurer denied the inpatient substance detoxification admission. The denial was reversed.

This male was admitted for inpatient substance detoxification treatment. He had withdrawal symptoms including tremors, nausea, stomach cramps, yawning, dilated pupils, restlessness, sleeping problems, irritable mood, anxiety, and high blood pressure of 140/79. He was using heroin multiple bags intra-nasally daily) and benzodiazepines, and had past cocaine and cannabis use. He had multiple past inpatient substance detoxification and rehabilitation treatments. He had comorbid depression and anxiety. He was placed on a detoxification protocol, Clonidine was also ordered, and he was discharged. 

The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that patients who fail to achieve abstinence, who relapse frequently, who fail to be cooperative with or benefit from outpatient detoxification, who currently abuse other substances, or who have 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 used multiple substances including heroin and benzodiazepines. He had comorbid depression and anxiety. He had active withdrawal symptoms on admission and he required detoxification medication to modify withdrawal.  He was at risk for death from overdose and at risk for severe withdrawal symptoms as he was using large amounts of heroin and also using benzodiazepines. According to the LOCADTR, he did require 24 hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting and was at risk for worsened withdrawal symptoms if not in this 24 hour setting. He likely would have relapsed again as evidenced by relapsing after past treatments, and by continued substance use despite negative consequences. 

Based on the above, the medical necessity for the inpatient substance abuse treatment services is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Large Carious Lesions 

Treatment: white glass with high gold content crown, tooth 10, tooth 21, tooth 22, tooth 25, tooth 26, tooth 27, tooth 7, tooth 8; nerve treatment on front tooth 10, tooth 22, tooth 25, tooth 26, tooth 27, tooth 7, tooth 8; nerve treatment on bicuspid tooth, Tooth 21

The insurer denied white glass with high gold content crown, tooth 10, tooth 21, tooth 22, tooth 25, tooth 26, tooth 27, tooth 7, tooth 8; nerve treatment on front tooth 10, tooth 22, tooth 25, tooth 26, tooth 27, tooth 7, tooth 8; nerve treatment on bicuspid tooth, Tooth 21. The denial was reversed.
 
This is a female patient who consulted her dentist to evaluate her options for comprehensive dental treatment. Endodontic therapy was recommended on multiple teeth as denoted above on teeth 10, 22, 25,26,27,7,8 and 21 due to large carious lesions encroaching on the pulp spaces with subsequent recommended treatment of full coverage crowns to be placed. A progress note from early 2019 states that the patient had a history of oral malignancy treated with postoperative radiotherapy and subsequent profound radiation induced xerostomia. It was also noted that wearing complete removable prosthesis was not practical or possible because of the inability to achieve suction for denture stability/support.

Upon review of radiographs and the clinical image, they support the recommended treatment. All teeth have large carious lesions involving the pulp chambers radiographically requiring endodontic therapy as identified by the dentist.  All have adequate residual coronal structure for support of crowns and minimal periodontal alveolar bone loss.  The standard of care in general dental practice would be endodontic therapy for these teeth which would have an excellent long term prognosis with the recommended treatment.

The carrier's denial of coverage for white glass with high gold content crown, tooth 10, tooth 21, tooth 22, tooth 25, tooth 26, tooth 27, tooth 7, tooth 8; nerve treatment on front tooth 10, tooth 22, tooth 25, tooth 26, tooth 27, tooth 7, tooth 8; nerve treatment on bicuspid tooth, Tooth 21 is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

The patient presents to the office of the dental provider for evaluation and treatment of tooth #13. The tooth recently underwent a root canal treatment through the crown. The health plan's determination of medical necessity is upheld in whole. The requested treatment is not medically necessary. Based on the radiographic documentation, there is not an issue with the current restoration on tooth #13. Even if a tooth did undergo a recent root canal treatment, replacement with a new crown is not always necessary unless there is a specific reason it is required. In this case, no rationale is submitted for review for the replacement of the current restoration hence no treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Dependence
 
Treatment: Inpatient substance detoxification admission

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

This is a middle aged male who was admitted for inpatient substance detoxification treatment in this hospital in early 2019 for alcohol and substance detoxification treatment. He reported that he had been drinking a lot of alcohol daily, and smoking cannabis or hashish. He had withdrawal symptoms including sweats, tremors, nausea, irritable and anxious mood, sleeping problems. He had a history of alcohol dependence, post-traumatic stress disorder (PTSD) and psychiatric hospitalization. He has had multiple past inpatient substance detoxification and rehabilitation treatments. He was unable to maintain abstinence on his own and lacked coping skills. His Clinical Institute Withdrawal Assessment of Alcohol Scale score was 4. He was put on a Librium protocol during his hospital admission and was then discharged.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders indicate 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. 

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 large amounts of alcohol despite multiple past inpatient substance detoxification and rehabilitation treatments. He required and needed detoxification medication (Librium) to modify withdrawal and prevent severe, complicated, or life threatening withdrawal. The risk of complicated withdrawal symptoms, such as delirium tremens can occur three to four days after alcohol use so he required the time in this hospital as he was considered at high risk for life threatening withdrawal including delirium tremens. He was unable to maintain abstinence on his own and lacked coping skills and also had comorbid psychiatric disorders and a past psychiatric hospitalization. 

Based on the above, the insurer's denial for the inpatient hospital services is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Issue under review: Inpatient rehabilitation

Determination:
The Inpatient rehabilitation was not medically necessary.

The patient presented with substance use disorders with use of opioid and cannabis class substances of abuse. Upon referral for substance use disorder treatment, the patient readily engaged in treatment with reasonable motivation due to his desire to return to employment and find housing. During the time interval under review, the patient was noted to be in no apparent distress with satisfactory daily functioning and active participation in treatment including positive interactions with staff and peers. There were no emerging treatment issues or biomedical or co-occurring psychiatric issues that would have warranted the inpatient level of care. The application of NY State OASAS LOCADTR Criteria (referenced below) did indicate that the patient was clinically appropriate for treatment with lower level care in a less restrictive treatment setting, as the health plan asserts. Thus, medical necessity for the Inpatient rehabilitation admission is not met in this case scenario. This answer is consistent with ASAM Criteria, the scientific literature and published guidelines, referenced below, as well as the application of NY State OASAS LOCADTR 3.0 Guidelines, referenced below.

The patient in this case scenario is not clinically appropriate for the admission or continued inpatient level of care during the time interval under review. The patient's clinical features did not include residual withdrawal symptoms, biomedical complications or co-occurring psychiatric symptoms or disorders that would have warranted inpatient level care. His treatment did not require 24-hour monitoring or the structure or intensity of inpatient level services. There were no safety concerns in this case. He readily engaged with treatment with reasonable motivation, and was involved with peer supported recovery groups while participating in educational sessions and other evidence-based treatment to address the substance use disorders. The patient could have been safely and effectively treated at a lower level of care in a less restrictive setting with sober supports and clinically appropriate monitoring to assure abstinence. Thus, the health plan's determination is reasonable in this case scenario. This answer is consistent with prevailing standards of medical practice for the substance use disorders diagnosed and under treatment in this case, as well as the NY State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.
Appeal type: Medical necessity
Decision: Upheld

The patient has a past medical history significant for obesity, right knee surgery, prior transient ischemic attack (TIA) for which she had received tissue plasminogen activator (tPA). She presented to the emergency department with a chief complaint of headache accompanied by left facial numbness as well as left upper and lower extremity heaviness. 

Given concerns for potential TIA versus hemiplegic migraine, the patient was admitted to the hospital. She underwent telemetry monitoring as well as magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the head and neck which showed no acute process. The day following admission, she was noted to continue to have weakness of her left arm. Ultimately, her exam returned to normal and she deemed stable for discharge. The health plan has denied the inpatient admission as not medically necessary. The health plan's determination is upheld. 

This patient presented with symptoms consistent with complicated migraine with left sided symptoms. Certainly, TIA/ cerebrovascular accident (CVA) needed to be considered in the differential diagnoses and in this setting, the patient underwent appropriate neuro-imaging that was all unremarkable. It is not noted in the record that the patient did not improve with treatment or that she had worsening symptoms. She did not have intractable headache, worsening or persistent neuro deficits, and she did not fail an appropriate period of observation. She could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pancreatitis
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
The treatment as provided was medically appropriate; however, the level of care at which the service was rendered was not medically necessary.
Despite the patient's presentation the care as provided could have been rendered in its entirety at a lower level of care. The patient had cocaine related abdominal pain; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for prolonged NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient admission
The inpatient admission was not medically necessary.


The patient is a female.   She presented to the emergency ward after a witnessed generalized seizure disorder.   At presentation, her neurological examination was normal. MRI brain was normal.  Electroencephalogram (EEG) showed bursts of four to six cycles per second, bifrontal activity seen lasting 0.5 to 1.0 second.  She was started on Keppra and discharged. 

At presentation, the patient had a normal neurological examination, negative CT of the brain and MRI brain.  She did not have any recurrent events suggestive of seizure.  The diagnostic studies, monitoring, and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Lumbosacral Myelomeningocele
 
Treatment:  Additional Physical Therapy visits

The insurer denied the Additional Physical Therapy visits. 
The denial was reversed.  

This is a young male child with spina bifida and congenital talipes equinovarus.  He has a diagnosis of lumbosacral myelomeningocele and requires bracing and therapies to maintain function and independence.  Per the physical therapist assessment in late 2018, the patient was referred to therapy with complaints of foot pain.  The exam revealed knee mobility deficits associated with gross motor difficulty secondary to spina bifida.  The recommendation was for weekly physical therapy (PT) to continue to work on flexibility and controlled mobility and balance. 
	
The criteria used to guide this decision were InterQual criteria for Outpatient Rehabilitation and Chiropractic Criteria.  This states that the outpatient rehabilitation and chiropractic criteria cover top referral diagnoses-including most nonoperative, preoperative and postoperative musculoskeletal diagnoses - Cardiac Rehab, Pulmonary Rehab, Traumatic Brain Injury, and Pediatric Rehab.  A Pediatric Rehabilitation subset covers medically complex pediatric conditions.  This allows for patients with continued skilled therapy needs to prevent or slow further deterioration.  Initial and ongoing review criteria consist of objective clinical indicators and therapeutic services.  Because the product provides unique visit patterns based on functional limitation, it is easy to determine what is clinically necessary based on the severity of the patient's diagnosis and functional limitation.

The carrier's denial of coverage for the additional physical therapy visits provided is reversed.  The medical necessity is substantiated.
Appeal type: Step Therapy
Decision: Overturned

Diagnosis: Becker muscular dystrophy
Issue under review: Emflaza

Determination:
The Emflaza is medically necessary.

In the patient's case, the patient is ambulatory and is able to work, maintains normal pulmonary function and reduced but stable cardiac function.  Considering that the natural history of the patient's muscular dystrophy is gradual decline, and Emflaza is the only medicine used, it can be concluded that this treatment maintains the patient's cardiac, pulmonary and motor functions steady.  Practice parameter:  corticosteroid treatment of Duchenne dystrophy:  report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society supports Emflaza as one of the treatment options within the standard of care.

Since the patient was proven to be stable on Emflaza over time, switch to prednisone, which may or may not be as effective, will carry unnecessary risk of cardiac, pulmonary and motor functions deterioration.  Since the patient's cardiac function is already compromised and his left ventricle is already fibrotic and dilated, such switch can lead to congestive heart failure and ultimately to the patient's demise.  Therefore, the proposed treatment is medically necessary. 

The patient's bast interest is to be continued on Emflaza, due to proven stability of his cardiac, pulmonary and motor functions on this medicine.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain, cramping, nausea, vomiting and diarrhea
Treatment: Inpatient admission 
The inpatient admission for the management of this patient with one day history of severe abdominal pain, nausea, vomiting and diarrhea was not appropriate and medically necessary. 

The patient presented with one day history of severe abdominal pain, 10/10 in severity, associated with nausea, vomiting and diarrhea, and normal to low grade fever. In the ED, she was treated with IV fluids, Zofran, Reglan, and Morphine IV times two. In the ED, she was hemodynamically stable and afebrile, and her abdominal examination was benign. Her CBC (complete blood count) revealed leukocytosis, and she underwent CT scan of the abdomen and pelvis, which revealed ileus/partial obstruction. She was evaluated by general surgery and GI (gastroenterology) consultants, and supportive treatment with antiemetics, and pain control, off antibiotics was recommended. The clinical impression was that the patient suffered from gastroenteritis. She was continued on IV fluids as well. The next day, her abdominal pain resolved and she was able to tolerate the diet. Her leukocytosis resolved off antibiotics. She was discharged home in fair and stable condition. Given this clinical scenario, the acute level inpatient care was not medically necessary. She could have been safely and appropriately managed under lower level of care, as she remained hemodynamically stable and afebrile during her admission, and she had no signs and symptoms of bowel obstruction, bowel perforation, peritonitis, etc to warrant any endoscopic or surgical intervention.