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

The patient was admitted following medical screening to acute inpatient level services for monitoring and detoxification and withdrawal management of severe alcohol and cocaine and cannabis use disorders. The patient was using up to two pints and one six pack of beer per day and $100 worth of crack cocaine as well as marijuana in varying amounts. The patient's referral for detoxification treatment was in the context of failing outpatient substance-related treatment with continued use of substances. The patient had experienced severe alcohol withdrawal in the past requiring detoxification services on multiple occasions, and she had extensive past substance use disorder treatment episodes including at least four rehabilitation treatment episodes in the year prior to presentation, as well as the ongoing outpatient treatment prior to admission. At the time of presentation and admission, the patient had a Clinical Institute Withdrawal Assessment (CIWA) scale score of 15 despite having a blood alcohol level of 0.036. She had tremors, sweats, auditory and visual disturbances, anxiety and mild agitation.

The health plan's determination is overturned. The patient in this case presented with a diagnosis of severe alcohol use disorder and comorbid stimulant and cannabis use disorders with history of relapse while in outpatient treatment, and, medical complications associated with substance use disorders with cocaine and alcohol and cannabis, as noted in the clinical summary. The patient also has history of PTSD and a mood disorder with ongoing treatment, as noted in the clinical summary.
The presenting clinical features and history and risk for withdrawal seizures and other complications of alcohol and stimulant/cocaine and cannabis use disorders did warrant the admission and continued inpatient level services with medical monitoring in this case scenario. The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could not have been provided at a lower level of care in this case scenario.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Abuse

Treatment:  inpatient substance abuse

The insurer denied coverage for inpatient substance abuse.  The denial was reversed.

This patient is a male who was admitted to this inpatient substance detoxification treatment for alcohol detoxification treatment.  He reportedly had alcohol withdrawal symptoms including tremors, yawning, sleeping problems, irritable mood, anxiety, nausea, and had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 17.  He reportedly was drinking 3 pints of vodka per day and smoking cannabis daily with over 2 decades history of alcohol use.  He had multiple past inpatient substance detoxification treatments including several in 2018 and one in early 2019.  He was unable to stop on his own, lacked coping skills, and ability to identify triggers.  He was unemployed.  He reportedly had a history of depression and past suicide attempt.  He was put on an Ativan protocol and discharged with the recommendation to attend inpatient substance rehabilitation treatment.

This reviewer disagrees with the decision to deny coverage for inpatient substance rehabilitation treatment with a referral for inpatient substance rehabilitation treatment, as the medical records provided enough specific evidence to support that he required inpatient substance detoxification 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.  In this case this patient had been using large amounts daily alcohol daily including up to 3 pints per day and also smoking cannabis.  

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 settings as he continued to use large amounts of alcohol daily despite reports that he had past inpatient substance detoxification treatments, as it was reported that he had multiple past inpatient substance detoxification treatment. He likely would have relapsed again as evidenced by relapsing after past treatments so it was not likely that he could safely and effectively be treated for detoxification in an outpatient setting.  It was unlikely that he would remain abstinent while having withdrawal symptoms which he reportedly had as his CIWA was 17 on admission. 

As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance detoxification as he was reportedly discharged. It did not appear that the health care plan acted reasonably or in the best interests of the patient then. 

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

Diagnosis: Alcohol use disorder
Issue under review: Inpatient detox admission

Determination: 
The Inpatient detox admission was medically necessary.

The requested Inpatient admission and substance use disorder treatment could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was large quantity of alcohol on a daily continuous basis that did warrant inpatient level detoxification and withdrawal management and monitoring; 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. The patient has substantial mental health issues and severe psychosocial stressors that also warranted inpatient level treatment. Moreover, the patient presented with moderately severe withdrawal symptoms that persisted throughout his inpatient stay, and the patient's social environment was not conducive to detoxification, and the patient's treatment occurred in the context of limited insight, impaired judgment and poor control of impulses with a more recent chronic relapsing clinical course and history.

Thus, the adult inpatient detoxification treatment and withdrawal management of this patient's substance use disorder did warrant the admission and the continued structure of an inpatient level detoxification setting with 24-hour monitoring and use of prn medications. The patient's history of substance abuse (frequency and quantity) together with the co-occurring psychiatric disorders, and severe psychosocial stressors and functional impairments reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure if the continued detoxification and withdrawal management were to have been 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, ASAM Criteria, and the scientific literature, referenced below, and New York State instruction for medical necessity reviews including the appropriate application of the NY State OASAS LOCADTR Tool that requires the patient in this scenario default to the higher level of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Missing tooth
Issue under review: Crowns

Determination:
The crowns are medically necessary, in part.

Specifically, the requested procedures are medically necessary for teeth 3 and 5. The patient only has one missing tooth in his mouth (tooth #4). Therefore, replacing that tooth with a bridge from tooth 3 to 5 is a viable option to correct this situation. Teeth 3 and 5 would be the anchor teeth for a new bridge. To replace the one missing tooth with a partial denture is absolutely not the correct plan. 

The requested procedures are not medically necessary for teeth 8 and 9. There is no evidence showing the need (e.g., recurrent decay or fracture) on these teeth for new crowns. The existing crowns look fine, and there is no evidence presented showing the need to replace them.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious Pneumonia
 
Treatment: Inpatient Admission

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

This is a young male patient who presented to the emergency department after having a syncopal episode. It was reported that the patient experienced shortness of breath and dizziness. He has no past medical history. His initial blood pressure upon arrival was 86/49; he was treated with intravenous (IV) fluids. A few hours later a repeat blood pressure was taken; it reported to be 120/88. A computer tomography of his head was preformed which was negative. A chest x-ray was obtained which revealed bilateral basilar alveolar opacities. A computer tomography of his chest was done which showed bilateral air space disease, possible edema verses toxin or infectious. An Echocardiogram was done which revealed mild left ventricular dysfunction with an ejection fraction of 41%. The patient received IV antibiotics to treat the pneumonia. The patient remained afebrile and hemodynamically stable and was safely discharged home.

The patient remained afebrile and hemodynamically stable. The patient was not hypoxic. The   blood pressure was stable after initial fluids in the ED. He was stable to be switched to oral antibiotics and he could have been discharged home after a period in observation with close follow-up in an outpatient setting. The prior denial is appropriate as this patient did not meet Milliman Care Guidelines criteria for inpatient acute level of care. The health plan acted reasonably and with sound medical judgment in the best interest of the patient. 

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

Diagnosis: Undiagnosed abdominal pain

Treatment: Inpatient hospital admission

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

This patient is a male who presented with right lower quadrant abdominal pain. The blood pressure was initially 98/66 but later that day was 120/60.There was no abdominal rebound or guarding. There was no leukocytosis. A CT scan of the abdomen and pelvis was negative for acute disease. A colonoscopy was done to look for Crohn's disease and was negative. The patient was able to tolerate a diet and remained stable.

Clinical indications for admission for undiagnosed abdominal pain (M05) include the need for surgery that cannot be performed on an ambulatory basis and the presence of peritoneal signs. The patient did not have these conditions. He also did not have hemodynamic instability, intestinal obstruction, bacteremia, a severe electrolyte abnormality or an inability to maintain oral hydration.

This patient required a workup for abdominal pain. However, he was stable to have had an outpatient workup including the colonoscopy. The intravenous (IV) hydration and anti-emetics could have been given in the emergency room.

He did not meet MCG Criteria for admission for "undiagnosed abdominal pain." The health care plan acted reasonably and with sound medical judgment in the best interest of the patient. The inpatient medical services were not medically necessary.

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

Diagnosis: Syncopal episode with sustained head trauma
Treatment: Inpatient stay

Summary:
The proposed treatment Inpatient admission is deemed medically necessary. 

The patient is a female who presented to the ER for further evaluation/management s/p syncopal episode with sustained head trauma. Intake vitals were notable for severely hypotensive blood pressure of 66/46 mm Hg and moderate hypoxemia on room air of 89%. Laboratory testing revealed numerous abnormalities including anemia with hemoglobin/hematocrit values of 10.5/31.3 and elevated lactate levels of 2.2. Maxillofacial CT revealed evidence of comminuted fracture of the tip of the nasal bones extending into the mid left nasal bone. 

The patient was admitted to the inpatient unit for further evaluation/management where she received treatment with Potassium Chloride, PRN analgesics and continuous telemetry monitoring. Plastic surgery consultation was obtained for her nasal fracture and nose was splinted using Aquaplast splint which was molded to her nasal dorsum. In addition, her hospital course was complicated by the presence of occasional premature ventricular contractions with bigeminy. Cardiology consultation was submitted and numerous outpatient cardiac studies were ordered. Patient was eventually discharged in stable condition. 

There are numerous aspects of this patient's clinical presentation and hospital course that justify the need for inpatient admission. First, the presence of severe hemodynamic instability with profound hypotension of 66/46 mm Hg, moderate hypoxemia on room air of 89% in the setting of moderate anemia of 10.5/31.3 and elevated lactate levels of 2.2 placed this patient at a much higher risk for increased morbidity and mortality in the setting of a syncopal episode with head trauma. For these reasons, the patient's care could not have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the proposed treatment of Inpatient admission is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cardiac Catheterization with placement of a drug-eluting stent
 
Treatment:  Inpatient Admission

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

This is a male patient, who was admitted for an elective cardiac catheterization with placement of a drug-eluting stent.  He has a past medical history of coronary artery disease, hypertension, hyperlipidemia, and diabetes mellitus.  There was no procedural complication noted; he was admitted overnight for monitoring.  The patient remained hemodynamically stable, was ambulatory and tolerating a diet.  He was discharged home with instructions to follow up with his cardiologist.  
 
Inpatient admission status was not medically necessary for this patient.  Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this procedure is an outpatient one.  The clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate.  There were no extenuating circumstances in this case that warranted inpatient admission status following elective cardiac catheterization and attempted angioplasty.  The health plan acted reasonably with sound medical judgment and 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

Bone Fracture/Break
Physical Therapy

The patient has a history of left foot surgery, including open reduction internal fixation. An appeal and subsequent request for medical necessity was made for physical therapy services. A letter from the provider indicates that the patient requires ongoing physical therapy to improve mobility, function and reduce ongoing pain symptoms.

The health plan's determination is upheld. The requested physical therapy is not medically necessary. The time period in question is approximately six month postop. Both the early and mid-rehabilitation cycles would have been completed by this point and the patient would be transferred to an independent exercise program for ongoing strengthening and range of motion improvements. Even in patients that were returning to high level sports activities transition to progressive strengthening exercises in an independent format at the 10 to 12 week postop time period is usual. Exercises to promote return of plantar flexion strength are systematic and progressive, and return to impact activities follows a safe, logical progression. All exercises are performed on two feet, progressed to eccentric only on the involved, to single leg, then a gradual progression of impact activities. These progressive exercises can be performed safely and independently once demonstrated and instructed by a trained physical therapist.
Appeal type: Medical necessity
Decision: Upheld

Psoriasis
Pharmacy/Prescription Drugs

This is a male patient with plaque psoriasis. The patient has previously used topical steroids and Otezla. The provider requests Cosentyx. This is the subject of this review.

The health plan's determination is upheld. Cosentyx is not medically necessary for this patient.
Per the plan, a trial of Humira, Stelara, and Taltz is required. All of these are Food and Drug Administration (FDA) approved for plaque psoriasis. National consensus guidelines advocate for the use of biologic such as Humira, Stelara, Taltz after first-line therapy with topical steroids have failed. Humira, Stelara, and Taltz are all FDA approved for the treatment of plaque psoriasis and psoriatic arthritis. In fact, Humira has amassed the longest published safety data of any drug FDA approved for the treatment of plaque psoriasis since 2008. The American Academy of Dermatology (AAD) guidelines show up to 72-75% psoriasis area and severity index (PASI) 75 reduction rate for Humira and Stelara, and 87% for Taltz.
The provider states that the patient has done well with samples, but there is no indication that the patient would not do well with the plan preferred therapy and there is no indication that the patient would experience adverse effects from a change in therapy. The prior authorization form indicates the patient has previously used Humira, however, this is not in any of the medical record submitted. The patient does not have a history of demyelinating disorder, congestive heart failure (CHF), lupus-like syndrome, or active infection. The patient is not immunosuppressed or immunocompromised. As the patient has no documented contraindication, intolerance, or failure (CIF) to Humira, Stelara, Taltz, there would be no exception for Cosentyx.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient came to the ED with two to three month h/o epigastric pain, which had worsened the day before after work, and the pain level increased from 5/10 in the evening before to 10/10 overnight, followed by nausea, vomiting, diarrhea in the early hour of the morning of the day of presentation, which brought him to the hospital. His pain was controlled with IV morphine and nausea, and vomiting was controlled with IV Zofran. His abdominal pain resolved later that day, and he did not have any vomiting after he was admitted. He was hemodynamically stable and afebrile. He had no signs of bleeding or infection. His CBC was normal with normal Hb/HCT (hemoglobin/hematocrit) and WBC (white blood count). He had markedly elevated transaminases and mildly elevated bilirubin and alkaline phos. His PT/INR was borderline elevated at 1.2. The lipase was mildly elevated. The right upper quadrant US (ultrasound) was normal, and CT scan of the abdomen revealed mildly dilated bile duct, cholecystectomy and s/p gastric bypass. The GI was consulted and MRCP was done, which did not reveal any biliary obstruction, stricture or stone. The hepatitis and other viral serologies, and autoimmune markers were sent as part of the evaluation for abnormal liver function tests. Overnight, the patient remained asymptomatic. The next day, was able to tolerate diet. His liver function improved significantly. 

Given this clinical scenario, the patient could have safely been kept under observation in the ED overnight, and once all the imaging studies revealed no biliary obstruction, and no endoscopic or surgical intervention was deemed necessary, and he was completely asymptomatic and tolerating diet, he could have been discharged home from the ED without requiring inpatient admission for the management of his condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Short cervix

Treatment: Inpatient admission

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

This patient is a female G6 P3023, who presented at 26.3 weeks gestation with complaints of cramp-like abdominal pain. The patient had a diagnosis of short cervix, was receiving progesterone and had a pessary inserted. There were no cervical changes reported and no evidence of uterine contractions. The patient was admitted and discharged a few days after. She was monitored in the hospital and received IV fluid.

According to the submitted information, this patient was admitted because of a short cervix and concern about premature delivery. Please note that neither the patient nor the fetus were in any jeopardy. There was no active bleeding, no fever and no ruptured membranes. The patient was not in labor. There were no cervical changes noted after a period of observation. There was no plan for delivery and vital signs were stable. Fetal heart rate was reassuring. 

The management that this patient received during her admission could have been easily done in a less acute setting. The patient could have been observed in the triage area and hydrated. Once the provider ascertained that there were no cervical changes, no abnormal vital signs, no anomaly of the fetal heart, the patient could have been sent home with close follow-up.

MCG guidelines list several clinical indications that included, condition requiring premature delivery, delivery, fetal distress or demise, among others. The patient did not have any of the listed indications. 

The inpatient hospital services were not medically necessary for this patient's management. The health plan acted reasonably with sound medical judgment.

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

Diagnosis: Right knee osteoarthritis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was reversed.

This patient is a female with osteoarthritis to her right knee. She was admitted to the hospital for an elective arthroplasty. Her post-surgical course was non-complicated. She had removal of pain catheter several days after admission. She felt light headed on that date. Monitoring was provided. She was discharged to subacute rehab.

The medical record demonstrates the patient underwent a complex and extensive surgical procedure. She required post-surgical management based upon the amount of pain anticipated and associated rehabilitative/anesthesia services necessary. A pain catheter was placed which required monitoring for position and effect. This type of operation requires rehabilitative services. After knee arthroplasty, these services initially can only be provided at inpatient setting. She would also require monitoring for blood loss as anemia is common after replacement surgery. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial is reversed.