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

The patient is requesting detoxification from alcohol and other substances of abuse including cocaine, opioid/buprenorphine and cannabis. There was psychiatric comorbidity in this case best characterized as unspecified depressive disorder treated with Lexapro 10 mg. The health plan denied inpatient substance use disorder detoxification treatment with withdrawal management and supportive measures as not medically necessary. The health plan's determination is upheld. The proposed inpatient detoxification treatment and other inpatient medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The clinical features and indicated treatment dimensions of this patient's alcohol use disorder, and other substance use disorders, did not require or warrant the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and ongoing treatment for an unspecified depressive disorder. Moreover, the patient had been evaluated and cleared with regard to safety concerns in the emergency department, and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or general medical concerns that would have warranted an inpatient level admission and treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: Inpatient substance rehabilitation

The insurer denied inpatient substance rehabilitation. That denial was reversed

This patient was admitted to inpatient substance rehabilitation treatment after being transferred from another facility due to a relative being there. She was using $100 of cocaine by smoking it daily, drinking 1/2 pint of liquor per day, and her urine toxicology was positive for cocaine and benzodiazepines.  She was in an inpatient substance detoxification treatment a few weeks prior, but left against medical advice (AMA).  She had reports of past inpatient substance treatment.  She had bipolar disorder and childhood trauma/abuse victimization.  She had past rehabilitation for substances. She relapsed right after inpatient substance detoxification treatment.  She took Buspirone and Seroquel.  She reportedly was discharged with a referral to Housing Works. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting.  Residential facilities provide a safe and substance-free environment in which residents learn individual and group living skills for preventing relapse.  

In this case this patient was considered in need of 24 hour residential treatment then as she relapsed immediately after a 24 hour inpatient detoxification treatment and she continued to use cocaine and drink alcohol despite negative consequences.  She had comorbid psychiatric and medical issues including having a diagnosis of Bipolar Disorder. 

According to the Level of Care for Alcohol & Drug Treatment Referral (LOCADTR) she met criteria for substance residential treatment as she continued to use multiple large amounts of serious substances despite treatment past inpatient residential treatment settings and inpatient substance detoxification settings, Partial Hospital Programs (PHP's), and even psychiatric hospitalization.  She had inability to maintain abstinence and had poor judgment in leaving the recent inpatient substance detoxification treatment AMA and relapsing shortly after that.  Without this structured and supervised therapeutic residential treatment, she likely would have relapsed quickly and likely would have not attended treatment as evidenced by the fact that she left previous inpatient treatment AMA.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient  with longstanding gastroesophageal reflux disease (GERD) on proton pump inhibitor (PPI) therapy, referred for surgical evaluation.
The patient's workup includes an Endoscopy which showed no Barrett's, a potential hydrogen (pH) study that revealed a DeMeester score 19 (normal < 4), an esophageal manometry which showed satisfactory bolus clearance, and a small hiatal hernia (0.8cm), and an Esophagram that revealed "severe" reflux.There is no other documentation of the patient's response to antisecretory therapy; the assessment mentions that she was there to discuss Linx vs. fundoplication.
HP determination is upheld. The LINX reflux management system is not likely to be more beneficial than any standard treatment for the patient's condition. This patient is asymptomatic on PPI therapy. As one of the most widely prescribed drugs worldwide, these are well tolerated medications and are highly effective. For patients who exhibit elevated distal esophageal acid exposure and persistent typical GERD symptoms despite maximal medical therapy, antireflux surgery should be considered. However, the issue is that for this particular patient, the surgeon has documented there are no symptoms of GERD on PPI therapy. LINX cannot be considered more beneficial to drugs that appear to be effective based on the documentation provided.
Appeal type: Experimental/Investigational
Decision: Overturned

This patient  sought surgical evaluation for the condition of gastroesophageal reflux disease (GERD) (heartburn, hoarseness) of more than one year duration.  Treated with prescription antacid medications (Nexium, Omeprazole, Ranitidine, Carafate), but has breakthrough and refractory symptoms. Denies dysphagia.
Esophagogastroduodenoscopy (EGD)showed esophagitis. Pathology showed no metaplasia. There was no hiatal hernia noted. Esophagram on showed normal esophageal motility and severe GERD. Testing of pH identified abnormal esophageal acid exposure with a DeMeester score of 19 over 48-hours of study (normal less than [<] 14.7). Esophageal motility on showed adequately preserved esophageal function and peristalsis. Lower esophageal sphincter relaxation was normal. The treating surgeon has proposed the LINX procedure as treatment of chronic GERD.
HP determination is overturned. This patient has been appropriately evaluated for the condition of GERD. Based on the volume and quality of the peer-reviewed literature cited below, the safety, effectiveness, and effect on health outcomes has been established for this patient. Reliable evidence shows that the LINX procedure is safe and effective for the treatment of GERD as is documented to exist in this case. LINX, in this case, is in accordance with generally accepted standards of medical practice in the U.S., is clinically appropriate and considered effective for the patient's illness, is not for the convenience of anyone and not more costly than alternative treatment and is not associated with scholastic education or vocational training.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient  has a history of longstanding gastroesophageal reflux disease (GERD) despite maximal strength proton pump inhibitor (PPI) with symptoms of hoarseness and change in her voice. Patient has had a  24 hour pH study was consistent with GERD with an elevated DeMeester score of 19. The patient had esophagogastroduodenoscopy (EGD) without evidence of Barrett's esophagus. Upper gastrointestinal (UGI) showed severe spontaneous reflux. Esophageal manometry was reported to be normal. The patient has not had prior bariatric or gastric surgery.
The provider recommends the LINX reflux management system. 
HP decision is overturned. The proposed LINX reflux management system is likely to be more beneficial than any standard treatment or treatments for the patient's condition.  Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and LINX procedure, which is Food and Drug Administration (FDA) approved for treatment of GERD. Both of these treatments have been shown in published studies to be more effective than medical management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression, suicidal thoughts
 	
Treatment: inpatient admission, evaluation and medical management

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

This patient was admitted for inpatient mental health treatment due to increased depressive symptoms including depressed mood, suicidal thoughts and plans to harm self by cutting self. Additionally, the patient had feelings of hopelessness and anhedonia, and she reported a history of substance use including cocaine and cannabis use, as well as hallucinogen use.  She had a history of aggression.  She had two past psychiatric hospitalizations, including one for severe self-injurious behavior by cutting her face severely and repeatedly with a box knife which required sutures.  She had medical issues including pelvic inflammatory disease and genital herpes.  She took Abilify Maintena and Celexa.  She had Assisted Outpatient Treatment (AOT) court ordered outpatient mental health treatment.  She was staying with her boyfriend.  She was discharged on 1/30/19. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors report that patients with suicidal intent or plan are in need of inpatient treatment.  In this case, this patient had suicidal intent and a plan to cut herself on admission and had past self-injurious behavior by seriously cutting her face in the past resulting in hospitalization; however, as of day 9, she had no further reports of suicidal ideation, plan, or intent, and had no self-injurious behavior.  Notes reported that she denied suicidal ideation and there were no reports of suicidal intent or plan or self-injurious behavior.  It also reported that her mood was good, she was looking forward to discharge, she denied suicidal thoughts, and her depression was greatly improved.  She was unable to urinate freely  the first 7 days , but by day 9 she was able to empty her bladder and initiate a urine stream.  There were no reports of psychotic symptoms, manic symptoms, current severe depressive symptoms or episodes, aggressive, threatening, or self-injurious behavior, agitation, or acute medical instability requiring 24 hour acute psychiatric hospital treatment.  As of day 9, there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in an acute 24 hour psychiatric hospital or that could not be achieved in a less restrictive setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mental Health (Major Depressive Disorder)
Treatment: Radiology Services (transcranial magnetic stimulation therapy)

Summary: This patient had depressive symptoms including depressed mood and had a diagnosis of Major Depressive Disorder-Severe. He had reports of 66 transcranial magnetic stimulation therapy (TMS) treatments in a 10 month period. The patient had reported financial stressors and lived alone. He had worsened depression; therefore, the request was for an additional 15 TMS treatment sessions. The patient was also taking Wellbutrin, Deplin, and Naltrexone. He had Prozac and Prazosin discontinued. 

The insurer has denied coverage for an additional 15 TMS therapy treatment sessions as not medically necessary. The denial was upheld.

There are no documented double blind studies showing the efficacy or safety of using maintenance TMS therapy for the treatment of patients with major depressive disorders who previously responded to past acute TMS therapy and who then had maintenance TMS therapy for the treatment of major depressive disorder. Additionally, there are no studies showing the efficacy or safety of long term TMS treatment beyond the standard recommended treatment recommendations, which is typically 36 sessions. There is no specific documentation or guidelines for the treatment of TMS after 66 TMS treatment sessions. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders considers TMS therapy as an appropriate acute phase option for patients who do not respond adequately to pharmacotherapy or psychotherapy and were considered treatment resistant. It does not mention that this is standard treatment for maintenance treatment after initial response to acute TMS therapy or for long term TMS treatment beyond the standard recommended typical 36 sessions. The Food and Drug Administration (FDA) did approve Neurostar Transcranial Magnetic Stimulation Therapy for the treatment of depression in October 2008 in patients who failed or who did not have satisfactory improvement from one past antidepressant medication at or above minimal effective dose and duration in the acute current episode, but the FDA approval was not for maintenance treatment or continuous long term TMS treatment.  The Psychiatric News June 3, 2016 reported that the body of evidence is starting to grow for maintenance TMS therapy, but that appropriate clinical trials specifically designed to answer questions related to maintenance are needed.  Furthermore, there are no clinical guidelines for the safety of 81 TMS sessions which is long term TMS treatment. This is the amount this patient would have after adding the additional requested 15 TMS sessions to the 66 TMS session done already in 10 months. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a medical history of atrial fibrillation, deep venous thrombosis (on anticoagulation with Xarelto), coronary artery disease, angina, vascular disease, lymphoma, hypertension, memory deficit, tremor, prior pneumonia, and osteoporosis. She presented to the emergency department with two weeks of intermittent diarrhea and rectal bleeding characterized by dark and bright red blood and recent increase in red blood. She noted an unintentional weight loss of 10 pounds and recent finding of a lung mass. The health plan's determination of medical necessity is upheld.
The patient had monitoring of clinical status, vital signs, serial labs, imaging, and specialist consultations, which were warranted [1]. Antiocoagulation was appropriately held. Flexible sigmoidoscopy without sedation provided a diagnosis. As hemodynamic status remained stable, and there was no hypotension or hemodynamic decompensation, and hemoglobin remained stable, all of the measures that were undertaken could have been performed at a lower level of care without inpatient admission .
Appeal type: Medical necessity
Decision: Upheld

The patient presented with one week history of dysuria, frequency, and urinary urgency. The patient had earlier been treated at another hospital for the same symptoms, diagnosed with a urinary tract infection and started on Bactrim.  The patient returned to the ER when the symptoms worsened. The health plan's determination is upheld.

The patient presented with symptoms consistent with a urinary tract infection. The patient was tachycardic and febrile on presentation and complained on back, flank pain, headaches and vomiting. The symptoms had worsened despite being started on oral antibiotics the day prior for a presumed urinary tract infection. There was however no documentation of acute kidney injury, urinary obstruction, perinephric abscess, altered mental status, intractable vomiting or pain, positive blood culture, failure of observation treatment, hemodynamic instability, or any other documented reason for an inpatient admission. The patient did not have any documented condition leading to a suppressed immune system such as uncontrolled diabetes mellitus or a solid organ transplant. The admission in this case did not meet criteria for medical necessity. The patient could have been safely and successful managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who two weeks prior had a sudden onset of right sided plegia and aphasia. An angiogram revealed critical left M1 short segment stenosis (80-90%). Magnetic resonance imaging (MRI) shows no stroke. He was started on aspirin and Plavix. The diagnosis was transient ischemic attack, middle cerebral artery stenosis. The plan was for balloon angioplasty and possible stenting. He has a family history of Von Willebrand disease.  The health plan's determination is upheld.

There is minimal evidence to show the submaximal angioplasty is safe and effective compared to medical management.

Wabnitz, et al states, "that although there is an intuitive appeal to treat symptomatic stenotic intra-cranial arteries with endovascular therapies such as angioplasty and stenting, current data from randomized trials showed intensive medical therapy is far superior for preventing stroke. 

Dumont, et al states, "Intracranial atherosclerotic disease (ICAD) accounts for approximately 10% of ischemic strokes. The recent Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) study demonstrated a high incidence of perioperative complications (15%) for treatment of ICAD with stenting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foot ulcer past medical history of diabetes with neuropathy, hypertension, hyperlipidemia and peripheral vascular disease

Treatment: Inpatient admission, bloodwork, intravenous medication

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

This patient was seen in the Emergency Department for acute swelling and pain to the right foot with difficulty ambulating.  The patient had a punched-out ulcer on the plantar surface of right foot 1 cm x 1 cm which he indicated had been present since about 7 months.  The patient was admitted two months prior for similar issues and was discharged with oral cefdinir. The patient was previously treated with IV antibiotics x3 days 6 weeks prior and had been on intermittent oral antibiotics with fluctuating improvement in symptoms.  The patient stated that the foot pain and swelling acutely worsened prior to presentation.  The patient received ceftriaxone, Flagyl and doxycycline in the emergency department.  The patient was admitted to receive treatment with IV ceftriaxone and vancomycin as well as oral doxycycline.  X-rays and venous scans were negative.  Wound debridement was completed at bedside.  

The medical literature indicates that inpatient admission is indicated for patients with cellulitis if there is failure of outpatient therapy as indicated by progression or no improvement after adequate trial minimum of 48 hours, with longer period for stable lower extremity infection as well as adequate antibiotic regimen and outpatient intravenous therapy is not appropriate.  Inpatient care may also be indicated if there is limb threatening infection, clinical presentation is judged to require intensity of patient monitoring that cannot be provided at an outpatient level care, high risk co-morbid condition, bacteremia, altered mental status is severe persistent, hemodynamic instability, suspected necrotizing soft tissue infection, orbital infection, oral cellulitis, cutaneous gangrene, periorbital or perineal infection that is severe progressive, severe pain requiring acute inpatient management, inability to maintain oral hydration or compartment syndrome monitoring.  

The documentation indicated that the patient has had a previous trial and failure of outpatient antibiotic medications.  The patient has had a fluctuation in symptoms.  However, there was no indication that the patient had progression or no improvement after an adequate trial of a minimum of 48 hours.  Furthermore, there was no indication that the patient could not utilize outpatient intravenous. Therefore, the patient's condition was appropriate for a lower level of care rather than inpatient level care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Inpatient detoxification

The inpatient detoxification/inpatient admission was not medically necessary for this patient.

The proposed inpatient detoxification treatment and other inpatient medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The clinical features and indicated treatment dimensions of this patient's alcohol and opioid use disorders, and other substance use disorders, did not require or warrant the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder without sustained sobriety or abstinence from substances of abuse. Moreover, the patient had been evaluated and cleared with regard to safety concerns in the emergency department, and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or general medical concerns that would have warranted an inpatient level admission and treatment. His vital signs were normal and the withdrawal symptoms were scored as mild or light.

Thus, admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario. Any indicated treatment for substance use disorder in this case could have been provided, as clinically appropriate, at a lower level of care following the comprehensive assessment and stabilization in the emergency department. 

This answer is consistent with established practice guidelines, the scientific literature, and ASAM Criteria, as referenced below, and is entirely consistent with NY State instruction for this review including the appropriate application of the NY State OASAS LOCADTR 3.0 Criteria, referenced below.

The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could have been safely provided at a lower level of care in this case scenario.

The patient in this case presented with continuous daily use of alcohol and heroin and intermittent use of cocaine and other substances of abuse; he did not experience complications related to withdrawal during his brief stay or present with severe symptoms of a co-occurring psychiatric disorder/depressive disorder, or abnormal findings on examination, or severe withdrawal symptoms, scoring a 5 (mild or light) on the CIWA scale for alcohol withdrawal. His risk for withdrawal complications including seizures and delirium tremens were minimal considering his history, and he did not pose a safety risk that would have warranted the admission and continued inpatient level services and monitoring, as requested.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg edema, Atrial fibrillation 

Treatment: Inpatient Hospital Admission

Summary:
The patient presented for exacerbation of diastolic CHF (congestive heart failure) and rapid atrial fibrillation due to medical non-compliance. He was re-started on diuretic and b-blocker with improvement in his symptoms. The patient had adequate oxygen saturation. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at an observational level of care.