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

Diagnosis: Alcohol use disorder
Issue under review: Inpatient detoxification

Determination:
The Inpatient detoxification was not medically necessary.

In this case scenario, the patient was amenable to treatment with lower level care in a less restrictive setting that could have provided the sober supports, structure and supervision necessary to transition or engage in rehabilitation services. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol. Moreover, as noted in the answer to question 2, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. Again, there were no severe symptoms of withdrawal or biomedical issues in this case. Thus, admission for acute inpatient level detoxification treatment, and the other requested inpatient level services were not medically necessary, as the health plan asserts. 

NY State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below, are not met for the proposed inpatient level of care that supports the health plan's determination of medical necessity and coverage decision. This answer is also consistent with prevailing standards of medical practice and the scientific literature, ASAM Criteria and the published guideline, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis
 
Treatment: Inpatient admission, monitoring

The insurer denied the inpatient admission. The denial was upheld.

The patient presented with nausea, vomiting and diarrhea. She was put on Amoxicillin the week before following a tooth extraction. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. A computer axial tomogram (CAT) scan suggested colitis. A stool for clostridium difficile was negative. The patient was treated with antibiotics. A colonoscopy was negative for inflammatory bowel disease.

MCG clinical indications for admission for Gastroenteritis (M-170) include having a suspected severe infection such as bloody diarrhea, severe abdominal tenderness, hemodynamic instability, severe vomiting, and severe dehydration. The patient did not have these conditions.

This patient had gastroenteritis. Intravenous hydration, anti-emetics, and stool testing could have been done in the Emergency Room. She remained hemodynamically stable. The vomiting resolved. The patient was stable to have had an outpatient colonoscopy. If antibiotics were felt to be necessary, they could have been given orally as an outpatient. The patient did not meet MCG criteria for admission for gastroenteritis. 

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

The patient is a male who was admitted for medically supervised inpatient withdrawal and stabilization services. The patient was seeking withdrawal management from alcohol and heroin. The patient reported using three bags of heroin daily and drinking 60 ounces of beer daily. He reported use of these substances the night prior to admission. The described having a prior detoxification attempt five months before this admission. He denied a history of withdrawal seizures or delirium tremens. There was no suicidal or homicidal ideation or auditory or visual hallucinations. He complained of withdrawal symptoms from both alcohol and opiates with Clinical Institute Withdrawal Assessment (CIWA) score of 13 and a Clinical Opiate Withdrawal Scale (COWS) score of 11 on admission. Scoring for CIWA was related to mild nausea, moderate tremors, barely perceptible sweats, moderate anxiety and agitation. Scoring for the COWS was for pulse of 81 to 100, sweating, restlessness, pupils larger than normal, mild diffuse discomfort, gastrointestinal (G.I.) upset, tremors, yawning, anxiety. Initial vital signs were within normal limits. Laboratory studies were generally unremarkable except for moderately elevated liver enzymes. The patient was prescribed a Librium taper for detoxification from alcohol and a methadone taper for detoxification from heroin. The health plan's determination is upheld. 
No, the inpatient substance abuse services were not medically necessary for this patient.

The patient did not have an immediate life-threatening medical condition or severe psychiatric crisis that required immediate hospitalization. Alcohol was the substance that had the most potential to cause harm to self or others. The patient met criteria for both alcohol use disorder and opioid use disorder. The patient was not in full remission from a substance use disorder. The patient was using a substance (alcohol) with risk of medical complications from withdrawal. The patient did not have serious psychiatric or medical symptoms that would require 24 hour inpatient medical management. The risk of withdrawal was not limited to opioids. Clinical documentation does not establish that the patient needed 24 hour medical oversight. The patient had a safe environment that could support outpatient treatment including management of mild withdrawal symptoms. It is not clear that ancillary withdrawal services were available to the patient. Using the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) criteria, the most appropriate level of care would have been Stabilization Services in a Residential Setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncopal Episode  

Treatment: Inpatient Admission

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

This is an elderly male who within the past two weeks prior to this presentation to the ED, was hospitalized twice for syncope.  He has a history of Parkinson's disease, Alzheimer's, hypertension, and benign prostatic hypertrophy (BPH), with home medications folic acid, multiple vitamins, amlodipine, carbidopa - levodopa, tamsulosin and aspirin.  Evaluation included unremarkable Holter Monitor, echocardiogram and stress test, except for a fixed inferior defect on nuclear scan.  Magnetic Resonance Imaging (MRI) of the brain was unremarkable and Computerized Tomography (CT) angiography of the head/neck revealed 50% bilateral internal carotid artery lesions.  A loop recorder was implanted on his last hospital admission and he was then discharged home. While home he complained of dizziness, laid down, and then his family noticed that his eyes rolled back into his head with no seizure activity, present pulse but brief apnea.  He was transported to the ED by Emergency Medical Services with initial vital signs in the ED at during this episode: blood pressure 118/75, heart rate 89 and oxygen saturation on room air 100%.  EKG revealed no T wave inversions or ST segment changes and chest x-ray was unremarkable.  ST segment changes and chest x-ray was unremarkable.  Laboratory test results included white blood cell (WBC) count 6.4, hemoglobin 12.7, BUN 25, creatinine 1.5 and troponin 0.02, with subsequent troponin was 0.01.  His loop recorder was interrogated and there were no arrhythmias.  He was treated with intravenous hydration and discharged on his home medications.

There is no evidence that this patient required an acute inpatient level of care to evaluate or treat his episode of presumed syncope. 

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

Diagnosis: Leg swelling; chest pain
Treatment: Inpatient admission
Inpatient level of care was not medically necessary.

The patient's chief complaint was leg selling which had been present for weeks. There was no significant concern for acute coronary syndrome (ACS). All tests were normal and the patient was asymptomatic except for previous swelling and cellulitis. 

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the "cardiac" symptoms were atypical and unlikely to be representative of acute coronary syndrome. Exam (blood pressure [BP] normalized) and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. Chest x-ray (CXR) was normal. Echocardiogram showed no wall motion abnormality.  Nuclear scan was negative for coronary artery disease (CAD). The physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for ACS such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG).  While there were findings of inflammation and enlarged nodes, no intervention was required. 

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of CAD. In fact, all tests showed absence of ischemia.  While there is always a potential for an adverse event, one did not happen and no actual treatment was added. 

Milliman criteria requirements were not fulfilled as there was never any evidence of ACS present. There was no "cardiology condition" that required inpatient level of care. All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncopal Episode
 
Treatment: Inpatient Admission

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

This is an elderly male patient who presented to the ER with weakness, dizziness, and fainting with a past medical history notable for hypertension, Benign Prostate Hypertrophy, and Parkinson's. He had been just discharged the day prior, and had an unremarkable workup including echocardiogram, Computerized Tomography (CT) angiogram, and Holter monitoring. EKG showed sinus bradycardia with T-wave inversions, similar to prior EKG. Laboratory testing was unremarkable. He was admitted and seen by cardiology, which recommended implantation of a loop recorder. This was done during this admission with no procedural complications as well as a nuclear stress testing. He was discharged home and instructed to follow-up with Cardiology in 2 weeks. 

The patient's care could have been administered in the observational level of service. There were no findings or features which justified the need for higher level of care. There were no high-risk findings prior to admission or subsequent to it during the initial evaluation. There was no concerning arrhythmias as cause for syncope, nor any signs or symptoms of myocardial ischemia, heart failure, cerebrovascular disease, or other general medical conditions warranting acute inpatient admission. The implantation of a loop recorder was not medically necessary as an inpatient, as this is an outpatient procedure. 

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

The patient presented to the emergency department (ED) with chest pain and dyspnea for the previous 2 days.  The patient also felt intermittent numbness of his left hand.  The patient had a history of hypertension and hyperlipidemia.  Physical examination was unremarkable.  An electrocardiogram (ECG) showed no ischemic changes.  Laboratory studies including troponin were unremarkable.  A Chest computed tomography (CT) in the ED was performed and did not show any significant abnormalities.
The patient was admitted and myocardial infarction (MI) was ruled out.  The inpatient stay is under review.

The health plan's determination is upheld.  The inpatient stay was not medically necessary.  The patient had chest pain suggestive of unstable angina.  It was reasonable to rule out a myocardial infarction.  This could have been done at a lower level of care.  Further diagnostic catheterization was reasonable to perform, and once it was clear that there were severe lesions on diagnostic catheterization, intervention was appropriate.  Follow-up after the intervention and the subsequent intervention could also have been performed at a lower level of care.  The inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a complaint of chronic left shoulder pain.  He underwent a left reverse total shoulder arthroplasty.  The patient was deemed stable for discharge to home the following day.  At issue in this case is the medical necessity of the inpatient hospital stay.
The health plan's determination is upheld.  The records show that this patient had an uneventful hospital course with no complications after a reverse total shoulder arthroplasty.  He received an antibiotic and pain medication; however, this could have been provided at a lower level of care than inpatient.  The current, peer-reviewed orthopedic literature has proven that outpatient and observation stay total shoulder arthroplasty is safe and has a lower complication rate.  A study published by Leroux and colleagues in the Journal of Shoulder and Elbow Surgery documented this conclusion.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with metastatic castrate resistant prostate cancer. The patient has previously received abiraterone, radium, and enzalutamide. He has received docetaxel but has had a complicated course due to toxicity. The patient has a somatic breast cancer antigen (BRCA) 2 mutation and Lynparza has been recommended; the medical necessity of Lynparza is under review.
The health plan's determination is upheld. The use of Lynparza as a single agent for the treatment of patients with prostate cancer in this clinical scenario remains the subject of ongoing investigation in National Clinical Trial (NCT) 03434158. There are 22 other studies currently open but none are evaluating this agent as monotherapy. Monotherapy has not been demonstrated to provide an outcomes benefit in this scenario. Lynparza is not recommended in the peer-reviewed literature, by the authors of UpToDate, nor by the National Comprehensive Cancer Network (NCCN) Guidelines for use in this clinical scenario. For these reasons, medical necessity cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Upper Gastrointestinal Bleeding
 
Treatment: Inpatient Admission

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

This is a female patient with a history of gastroesophageal reflux disease, hiatal hernia status post fundoplication, alcohol abuse, and marijuana use who presented to the Emergency Room in early 2019 with abdominal pain, vomiting of coffee grounds, hematemesis, and the inability to tolerate oral intake; her abdominal pain that improved with Pantoprazole. She was afebrile and the vital signs were stable.  The hemoglobin was 14.1.  The platelets were 258,000.  The international normalized ratio (INR) was 1.0.  An endoscopy revealed a prior fundoplication, esophagitis, gastritis and a duodenal ulcer which was not bleeding. 

Clinical indications for admission for upper gastrointestinal bleeding (M-180) include ongoing bleeding, high risk endoscopic features, cirrhosis, coagulopathy, and severe thrombocytopenia.  The patient did not have these conditions.  She also did not have hemodynamic instability or a severe anemia.

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

The patient is a male who presented for an elective cardiac catheterization and intervention secondary to chest pain and shortness of breath and a positive dobutamine stress echocardiogram. The patient had a history of hypertension, hyperlipidemia, and benign prostatic hyperplasia (BPH). The patient was found to have a 75% mid left anterior descending (LAD) lesion and 99% circumflex lesion. Both lesions underwent drug-eluting stenting. There were no complications. The patient was admitted, observed overnight and discharged the next day. The health plan's determination is upheld.

An inpatient hospitalization was not medically necessary for this patient.
The patient had an elective coronary intervention. The patient was found to have a 75% mid left anterior descending (LAD) lesion and 99% circumflex lesion. Both lesions underwent drug-eluting stenting. There were no complications. It was reasonable to observe the patient for several hours after intervention to assure clinical stability and no adverse cardiac outcomes or bleeding. The risk of a complication after several hours is low enough that full admission is not medically necessary. The patient could have been appropriately managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

This is the case of a female with past medical history significant for hypertension, hyperlipidemia and breast cancer in remission, who presented to the emergency department with chief complaint of epigastric pain with associated back pain that was 5/10, constant, pressure-like for the past day. She denied arm pain, jaw pain, pleuritic pain. Otherwise review of systems was positive for nausea as well as palpitations with associated dizziness for the past several months, in addition to constipation. The health plan's determination is upheld.

This patient presented with abdominal pain and chest pain that was atypical and associated with negative troponins and an EKG that was not suggestive of acute ischemia. The impression of the admitting physician was that the pain was likely gastrointestinal in nature. Monitoring the patient was certainly reasonable given the patient's age and other risk factors, but in the absence of ongoing cardiac-sounding chest pain, biomarkers and EKG suggestive of ischemia, arrhythmia, hemodynamic instability, or other acute reason for needing admission for chest pain such as dissection, pulmonary embolism, etc., acute inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

The patient is a male with a history of end stage renal disease on hemodialysis through a right upper arm arteriovenous (AV) fistula.  Other comorbidities include human immunodeficiency virus (HIV) and hypertension.  There was difficulty with hemodialysis, and it could not be completed.  Patient was noted to have some bleeding, and there was concern for possible AV fistula thrombosis.  The patient was sent to the emergency room where the patient was found to be hyperkalemic (5.8).  Patient was treated medically and was taken by the vascular surgeon for an upper extremity fistulagram and angioplasty.  The fistula was then used for hemodialysis, and the patient was discharged home the same day.

The inpatient services and treatment for this patient were Medically Necessary based on the peer reviewed literature.  This procedure fixed the stenotic outflow of the fistula and its resultant malfunction, and the patient was able to successfully receive dialysis.  Inpatient admission for this patient with multiple medical comorbidities and acute hyperkalemia was Medically Necessary.  Management of acute hyperkalemia and fistula malfunction on a strictly outpatient basis is not possible if hemodialysis cannot be performed on the patient as usual.  Thus, admission to the hospital was the safest and most medically necessary plan of action.  The vascular surgeon was able to perform a prompt fistulagram and angioplasty and discharge the patient home.  The health plan determination is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chronic Serous Otitis Media, Bilateral, Dysphonia, Hypertrophy of the Adenoids, stenosis of the larynx
 
Treatment:  Inpatient Hospitalization

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

This case involves a young female patient with a history of dysphonia, chronic serous bilateral otitis media, hypertrophy of the adenoids, and stenosis of the larynx and other specified diseases of the upper respiratory tract.  In early 2019 the patient presented to the ambulatory surgical center for a scheduled surgical procedure.  The pre-operative diagnosis was chronic serous otitis media, bilateral, dysphonia, hypertrophy of the adenoids, other specified diseases of the upper respiratory tract and stenosis of the larynx.  There was documentation that the procedure performed was MicroDirect laryngoscopy, bronchoscopy, excision of laryngotracheal stenosis, balloon dilation, bilateral injection laryngoplasty, bilateral myringotomy with ear tube placement, adenoidectomy.  There is no documentation of post-operative complications, the patient remained stable and was discharged.

The MCG clinical indications for ambulatory surgery procedures are:  no inpatient care is needed for preoperative disease or condition, not an emergent procedure, no complex surgical approach or situation anticipated, low-risk procedure or patient not a high anesthetic risk, no drug-related risk and no inadequate outpatient care situation is documented.  In the clinical records submitted for review, there was documentation that the patient presented to the ambulatory surgical center for MicroDirect laryngoscopy, bronchoscopy, excision of laryngotracheal stenosis, balloon dilation, bilateral injection laryngoplasty, bilateral myringotomy with ear tube placement, adenoidectomy.  There was no documentation of post-operative complications.  The patient remained stable.  There was no documentation of a rationale for the overnight stay on an inpatient basis.  

The carrier's denial of coverage for the inpatient hospital services is upheld.  The medical necessity is not substantiated.