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

Diagnosis: Substance abuse
Treatment: Inpatient detoxification

The proposed treatment, inpatient detoxification, was medically necessary for this patient.

The requested benefit of 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 crack cocaine that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. Detoxification, as indicated, 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. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms (tremor, sweats, headache, anxiety, irritability, restlessness and insomnia) which were being effectively addressed with Librium and supportive measures. The patient had associated clinical features that included a depressive disorder treated with Zoloft, and he presented with a lack of sober supports and limited insight, impaired judgment and poor control of impulses. 
	
Thus, the adult inpatient stay and continued detoxification treatment of this patient's substance use disorders did require the admission and the continued structure of an inpatient level setting with withdrawal management and psychosocial supports, and 24-hour monitoring. The patients history of substance abuse (frequency and quantity) together with the co-occurring depressive disorder and severe psychosocial stressors and functional impairments do 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 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, New York State instruction for medical necessity reviews including the appropriate application of NY OASAS LOCADTR 3.0 Criteria-referenced below.

The requested benefit of inpatient detoxification is clinically appropriate, medically necessary and warranted, and is therefore a covered benefit in this case scenario. The admission and the continued inpatient level treatment through discharge could not have been safely or effectively provided with lower level services, as noted above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease, past medical history of asthma, hypertension, and Anxiety

Treatment: Inpatient admission, diagnostic evaluation, and medication management

The insurer denied inpatient admission. That denial was upheld

This patient presented to the Emergency Department (ED) with complaints of worsening shortness of breath and chest pain. She has had multiple visits to ED for chronic obstructive pulmonary disease exacerbations. The patient had been admitted earlier and signed out against medical advice (AMA). This patient was being evaluated for a lung mass but signed out; she was non-compliant with medications, and she had run out of her Advair a week prior. Her vital signs at presentation: Temperature 97.6F, respiratory rate (RR) 18, blood pressure (BP) 113/80 mm Hg, oxygen saturation 100%. She was in mild distress, breath sounds were decreased and wheezing was present. The patient was awake and alert. Non- focal neuro exam.

White blood cell was 7K, hemoglobin (Hb) 9.9, Electrolytes were with in normal limits, blood urea nitrogen/ creatinine 12/0.69, brain natriuretic peptide 17, troponin 0.0. CPK 49
The chest X ray (CXR) was no acute infiltrates, left upper limb (LUL) opacity concerning for malignancy (which was seen earlier too), EKG normal sinus rhythm (NSR). No acute ST-T Changes. As per the history and physical the patient was in no acute distress. She was speaking full sentences. Her temperature 98.1F, heart rate 64, respiratory rate 18, blood pressure 109/76 mm Hg, oxygen saturation 96%. There was no use of accessory muscles; faint wheezes bilateral. The ECHO showed normal left ventricular Function, mild tricuspid regurgitation, CT chest revealed bilateral emphysema, left upper lobe density and left lover density, Mediastinal and Hilar adenopathy. There was possible malignancy (This was an old finding also seen on prior admission).

She was afebrile and hemodynamically stable. There was no chest pain at the time of the exam. Cardiac enzymes and EKG were normal, chest x-ray old finding of left upper lobe density; no pneumonia. Arterial blood gas (ABG) on room air 7.45/45/55/31/87 %, she was seen by Cardiology. The clinical impression was that the patient's chest pain was likely from asthma exacerbation and likely musculoskeletal in origin.

This patient did not need acute hospitalization. Observation status was appropriate for her. She could have been discharged once acute coronary syndrome was ruled out by serial cardiac enzymes and EKG. Further diagnostic work up could have been pursued in outpatient setting.

This patient did not need acute hospitalization. Observation status was appropriate for her. She
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain (sickle cell disease)
Treatment: Inpatient admission
The proposed treatment of inpatient admission is not deemed medically necessary. 
This female patient, with a history of sickle cell disease and recurrent pulmonary embolism, presented to the ER for further evaluation/management of chest, back, hip and leg pain. Intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. Examination was non-focal with no significant abnormalities noted including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen. Laboratory and ECG testing was also within normal limits with exception of mild chronic anemia. The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where she received supportive care with IV fluids and prn analgesics. She responded well to the prescribed therapies and was subsequently discharged in stable condition. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting the patient's safety or outcome. For these reasons, the proposed treatment of inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a medical history of coronary artery disease with prior stent placement (and ongoing aspirin and Plavix use), cardiac dysrhythmia, multiple prior episodes of pancreatitis, diabetes mellitus type 1, hyperlipidemia, hypertension, and appendectomy. He presented to the emergency department  with bilateral upper abdominal pain radiating to his back (9/10 in severity). Per the emergency department attending note, the pain was reported to feel similar to prior episodes of pancreatitis, but "acute pancreatitis seems unlikely primary diagnosis".  
The health plan's determination of medical necessity is upheld. The patient had abdominal pain consistent with acute pancreatitis, but imaging was not consistent with pancreatitis and the lipase was not three times the upper limit of normal, as required for pancreatitis according to guidelines.There was a lack of hemodynamic instability, organ failure, pleural effusion, or other sequelae to justify acute inpatient level of care, and the treatment provided could have been provided without the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral Hip Pain

Treatment: Hip arthroscopy

The insurer denied hip arthroscopy and related hospital services. That denial was upheld.

This patient presented for surgery with a six-year history of bilateral hip pain of unknown origin. She believed the pain began as a result of dancing.  She stated the pain started spontaneously and there was no known traumatic injury.  The pain will occasionally radiate down both of her legs and into her feet and buttocks.  She has had a trial and failure of injections, physical therapy, activity modification, anti-inflammatories and rest.  The patient complained of popping and clicking, as well as an antalgic gait at times. 

The last clinical note provided for review prior to the admission for surgery was from early 2017 when she was again seen in consult. This note refers to imaging done in 2015 including MRIs, "which showed findings consistent with FAI [femoroacetabular impingement] with insufficient offset at the femoral head-neck junction." He also noted the lack of any benefit of steroid injection done in 2015. At the 2017 visit, he noted her hip motion was "somewhat limited" both in flexion and internal rotation secondary to pain. Impingement test was markedly positive bilaterally. Otherwise her hip motion is full. Neurovascular exam noted no abnormality. The assessment/plan indicated "consistent with femoroacetabular impingement" and she needs to consider surgery.  Surgery consult was recommended.  No records of any more recent evaluation prior to her surgery were provided for review.   

On admission for surgery, the exam noted that objectively, the patient had 5/5 strength with intact sensation to the lower extremities.  The exam revealed left hip flexion from 0-110 degrees bilaterally with external rotation to 60 degrees and internal rotation to 20 degrees.  It was recommended the patient proceed with a bilateral labral repair with osteochondroplasty and tenodesis.  

With regard to the surgery performed, the documentation provided no clear indication that the patient was appropriate to undergo surgical intervention.  No clinical evaluation from 2017 to the admission for surgery was provided. No reports of imaging and no reports of the imaging done in 2015 were provided. While it was noted the patient did have pain with the failure of conservative measures, the lack of documentation over large periods of time and lack of imaging leaves it unclear whether the patient is an appropriate surgical candidate. The literature also indicates hip arthroscopy procedures are ambulatory procedures.  The documentation noted that the patient presented to undergo surgical intervention. Furthermore, a five-day inpatient stay is not recommended for patients undergoing arthroscopic repair.
Appeal type: Medical necessity
Decision: Overturned

The patient has diagnosis of renal cell carcinoma and underwent a partial nephrectomy. Pathologic stage was T3a. A computed tomography (CT) scan did not show any recurrence. The patient's provider requested a repeat CT scan that the health plan has denied as not medically necessary. Medical necessity for repeat CT scan is under review.
The health plan's determination is overturned.

The requested CT scan of the chest is medically necessary.
National Comprehensive Cancer Network (NCCN) Guidelines on Renal cell carcinoma, 2019 recommends CT scan every 3-6 months until year 3 and yearly thereafter until year 5 for Stage III (as was the case with this patient).
The European Association of Urology (EAU) Guidelines on Renal cell carcinoma, 2018 states, "The sensitivity of chest radiography and ultrasound (US) for small metastases is poor. The sensitivity of chest radiography is significantly lower than CT-scans, as proven in histology controlled comparative trials. Surveillance with these imaging modalities should not be done. When the risk of relapse is intermediate or high, CT of the chest and abdomen should be performed." This patient has high recurrence risk.
As such, the requested CT of the chest would be considered a clinically appropriate and generally accepted standard of care for management of this patient's medical condition. Hence, the requested CT scan would be considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriatic Arthritis

Treatment: Medication management - Xeljanz

The insurer denied the medication Xeljanz. That denial was reversed.

The has psoriasis, PsA (psoriatic arthritis), gastroesophageal reflux disease (GERD) and NASH (nonalcoholic steatohepatitis).  He has failed treatment with SSZ (sulfasalazine) and Cosentyx.  He has received Xeljanz since 11/2018 and continues to have a good response with decreased arthritis as noted at a 4/5/19 visit.  There is a history of an episode of colitis in 06/2018.  At issue is coverage for Xeljanz.

The insurer has denied coverage, noting that use of Xeljanz is not approved without concomitant oral non-biologic disease modifying anti-rheumatic drug (DMARD) therapy with such agents as methotrexate, leflunomide or SSZ.

In an appeal letter, his physician notes that multiple treatments including SSZ have failed.  Xeljanz has helped his arthritis.  He also notes that the patient has non-alcohilic fatty liver (NASH), and he would therefore avoid methotrexate or leflunomide.  

Xeljanz is Food and Drug Administration (FDA)-approved for PsA (and ulcerative colitis). The labelling does not require concomitant use of an oral non-biologic DMARD; it can be used as a sole agent.  In www.uptodate.com chapter "Treatment of psoriatic arthritis" there is no requirement to combine Xeljanz with such an agent.  The labeling does note that Xeljanz is indicated in those who have failed methotrexate or other oral agents.  He has failed SSZ.  In this case, with NASH, the treating MD is concerned about an increased risk of liver problems.  While Xeljanz can cause liver function test (LFT) abnormalities, the risks would be higher with leflunomide or methotrexate (liver toxicity is a major issue with both). 

This reviewer cannot find support for the requirement that Xeljanz be added to an oral non-biologic DMARD.  If the requirement is that the patient fails an oral non-biologic, he has already failed SSZ and has chronic liver disease that would make methotrexate or leflunomide riskier, as liver toxicity is a major issue with both.  The medical record shows a contraindication to the patient utilizing the formulary options listed by the insurer as methotrexate and leflunomide have increased risk due to NASH. 

In this case, the patient has failed SSZ and other formulary options have increased risk. Use of Xeljanz is supported in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic colon cancer
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

This patient could have been managed at an alternative level of care such as observation.  Acute level care was not warranted. She was clinically stable with stable labs that would be expected given her underlying medical condition of metastatic cancer and non-compliance with chemotherapy.  IV fluids could have been initially given in an observational setting.  In addition, the patient could have spoken with the surgeon in an observational setting; however, there is no role for surgical intervention in a patient with widely metastatic colon cancer non-compliant with chemotherapy.  Her labs could have been followed in observational care and would have likely improved with intravenous fluids. 

Therefore, acute level care was not necessary as it exceeded the scope of care of reasonable services for this individual and these services could have been given in a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient was admitted for acute inpatient level care for worsening symptoms of depression and suicidal ideation in the context of self-injurious behavior (SIB) and severe psychosocial stressors within the family constellation.  The patient's symptoms of depression had intensified due to family stress/conflict; he reported anxiety, depression, and suicidal ideation in the context of self-mutilation with cutting.
Diagnoses included adjustment disorder with depressed mood with stressors within the primary support domain.  The treatment team also worked to rule out posttraumatic stress disorder.
The patient received safety monitoring and treatment that included individual, group, psycho-educational and activity therapies including therapy to address the mood disorder and counseling to address the family discord.  The patient was prescribed medication, Lexapro, titrated as clinically appropriate.  The health plan's determination is overturned.

The behavioral health inpatient hospital service was clinically appropriate, reasonable, and in the best interest of the patient; who had severe symptoms of depression, and was a continued safety risk, and risk of worsening/severe symptoms of depression in the context of deterioration in functioning and SIB.  The patient remained a safety risk and functionally impaired with high risk for relapse/regression if discharged from acute inpatient level care early, and the patient needed to reach a stable baseline of functioning prior to discharge from inpatient level care with the development of a safety plan in concert with family, who was the primary source of support.
Thus, it was medically necessary for this patient to remain in the behavioral health inpatient setting in order to continuously assess the risk of suicidal behaviors, to address the acute risks associated with a return to the community with the noted psychosocial stressors, and to develop a safe and clinically appropriate discharge plan and disposition with clinically appropriate aftercare.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pectus excavatum

Treatment: Preparation of moulage for custom breast implant

Summary:
Based on the clinical information provided, there is no physiologic functional deficit secondary to the pectus excavatum, nor would there be physiologic functional improvement with a custom silicone implant placement. Therefore, preparation of moulage for custom breast implant is not considered reconstructive. Any improvement would be based solely on improved appearance. Based on the medical literature and the consensus of the medical/surgical community, the procedure is instead considered cosmetic and therefore not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency department (ED) with signs and symptoms of acute appendicitis; a computed tomography (CT) scan demonstrated acute appendicitis. He was admitted and taken to the operating room (OR) for an uncomplicated laparoscopic appendectomy. Postoperatively, his recovery overnight in the hospital was uneventful. He was discharged in good condition the next day. The health plan's determination of medical necessity is upheld. An inpatient stay was not medically necessary. The patient was stable on admission and during recovery. There was no evidence of abdominal sepsis from the acute non-perforated appendicitis. The procedure was straightforward, uncomplicated, and well-tolerated. Recovery was uneventful.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Altered mental status, fever, tachycardia
Treatment: Inpatient admission

The Inpatient admission was medically necessary.

The patient is a male with a history of heart failure, cardiac amyloidosis, diabetes mellitus type II, hypertension, end-stage renal disease with dialysis dependence, chronic hepatitis B cirrhosis, and iron deficiency anemia secondary to small bowl angiodysplasia. He presented to the Interfaith Medical Center Emergency Department (ED). He had missed a number of HD (hemodialysis) sessions. The patient developed acute altered mental status, fever, tachycardia, and was found to have gram negative rods on blood culture, concerning for sepsis secondary to acute bacteremia that was potentially a line-associated infection, which required urgent treatment with intravenous fluid hydration, intravenous antibiotics, and close inpatient monitoring.

The patient was critically ill at presentation and required an inpatient admission.

The patient developed acute altered mental status, fever, tachycardia, and was found to have gram negative rods on blood culture, concerning for sepsis secondary to acute bacteremia that was potentially a line-associated infection, which required urgent treatment with intravenous fluid hydration, intravenous antibiotics, and close inpatient monitoring.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Malocclusion
Treatment:  Braces

The braces are medically necessary.

The patient has a severe class II malocclusion (i.e. retruded mandible).  This can lead to TMJ (temporomandibular joint) issues in the future.  She also presents with and anterior open bite.  This can make it hard to incise (chew) food properly.  More importantly, she presents with impacted upper permanent canines.  This is an "automatic qualifier" on the handicapping scale (impacted permanent anterior teeth, where extraction is not indicated).  Having her upper canines placed in their proper position through orthodontic treatment is very important.  This case has a definite medical necessity.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Multiple pain complaints
Treatment: 98941 x 12, 98942 x 4 - Chiropractic treatments

The 98941 x 12, 98942 x 4 - chiropractic treatments were medically necessary, in part.

According to the documentation, the patient is a male with a history of multiple pain complaints. However, no specific etiology is noted through the records submitted.

The patient presented to the chiropractic offices. Upon evaluation, the attending chiropractor diagnosed the patient with the following: segmental dysfunction to the head, cervical, thoracic, lumbar, pelvic and sacral regions, spinal enthesopathy, low back pain, headaches, cervical disc degeneration, as well as segmental dysfunction to the lower extremity. A course of treatment was provided to the patient by the chiropractor, which included manual manipulative treatment to the spine as well as extremity. 

Moreover, the patient underwent spinal x-rays which results as interpreted by a medical radiologist revealed cervical spine multilevel degenerative changes, worse at the C3-5 levels.

Specifically, documentation presented for review does support a trial course of chiropractic care/treatment as provided to the patient by the chiropractor. However, documentation presented by the chiropractor fails to reveal that the patient was achieving any significant objective clinical gains with the chiropractic care/treatment being provided beyond a certain point. Therefore, part of the chiropractic treatments were medically necessary, and part of the chiropractic treatments were not medically necessary.

As outlined above, documentation presented for this review would support some of the chiropractic care provided. This would include a proper history, examination performed as well as a treatment plan provided. However documentation presented by the chiropractor fails to document the necessity of the continued ongoing chiropractic care/treatment being provided beyond a certain point. The daily records fail to reveal any significant changes in pain levels through the course of chiropractic treatment with waxing and waning of the patient's complaints.