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

Diagnosis:  OSA & Delayed awakening from anesthesia
Treatment:  Inpatient admission
The inpatient admission was not medically necessary.

All records were reviewed.  The patient is a young girl with a history of adenotonsillar hypertrophy with OSA.  The provider performed a T&A, and the patient was admitted as an inpatient for one day.  There was a history of prolonged awakening after a previous surgical procedure.  This patient underwent the T&A without intraoperative or postop complications.  There was no excessive bleeding.  The patient's pain was controlled, and the patient was ingesting by mouth (PO).  Vital signs were stable, and the patient was afebrile.  Based on the above, the medical necessity of the inpatient stay cannot be confirmed.  Patients with this clinical condition are typically observed overnight.  Care of a patient with this patient's condition could be performed at an observation level of care.  Therefore, the medical necessity of the inpatient stay is not confirmed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Detoxification
 
Treatment: Inpatient Admission

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

This is a male patient who was admitted to inpatient substance rehabilitation treatment in late 2018. He was smoking substances 3-6 times per week and smoking cannabis up to 5 blunts per day. He had multiple past inpatient substance rehabilitation treatment including not completing one three weeks prior to this admission. He reportedly lacked support and coping skills to maintain abstinence. He was noted to spend most of his free time using drugs. It was reported that he worked on better identification of relapse triggers, improving coping skills and relapse prevention skills. 

Patient documentation provided enough specific evidence to support that he required 24 hour inpatient substance rehabilitation treatment. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient treatment is indicated primarily for individuals 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. In this case this patient was considered in need of 24 hour substance rehabilitation treatment as he was using substances 3-6 times per week and cannabis daily and was unable to stop use. 

According to the LOCADTR he met criteria for inpatient substance rehabilitation treatment as he continued to use multiple substances despite treatment multiple past inpatient substance rehabilitation treatments including a recent one 3 weeks prior to admission which he did not complete He reportedly lacked supports. He reportedly needed to better identify relapse triggers and needed motivation for change and to build sober supports and develop relapse prevention skills. He was unable to stop substance use without being in a sober and supervised therapeutic inpatient substance residential setting then. Without this structured and supervised therapeutic residential treatment he likely would have relapsed quickly and had more negative consequences due to use. 

Based on the above, the medical necessity for the inpatient hospital services inpatient level of care is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity, Polycystic ovary syndrome
Treatment: Saxenda 

Summary:
In this case the patient is a woman with a current BMI (body mass index) of 36.7 kg/m2 comorbid health conditions of PCOS (polycystic ovary syndrome).  Initiation of Saxenda is medically necessary per FDA prescribing information and would be expected to be health beneficial for this patient in conjunction with a reduced calorie diet and exercise program.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a history of moderate persistent asthma who presented to the emergency department with wheezing and shortness of breath. His past history is significant for moderate persistent asthma, and his medications include budesonide twice a day and albuterol as needed. He had 3 prior emergency visits for asthma.
The health plan's determination of medical necessity is overturned in whole.
This patient presented with status asthmaticus. He continued to have significant wheezing and increased work of breathing despite appropriate treatment at home as well as intensive treatment in the emergency department. Upon arrival to the hospital floor, he continued to have significant wheezing and initially required albuterol every 2 hours as well as intravenous fluids to maintain his hydration status. He also required close monitoring with prompt treatment if his respiratory status worsened.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain and pleuritic chest pain

Treatment: Dialysis

The insurer has denied inpatient admission. That denial was upheld.

The patient is a male patient with a medical history significant for hypertension, diabetes mellitus type 2, asthma, obstructive sleep apnea, hepatitis C virus (status post treatment), cirrhosis, cholecystectomy and end-stage renal disease on hemodialysis. The patient presented to the Emergency Room with complaints of abdominal pain, nausea, vomiting, diarrhea, and pleuritic chest pain. He missed two hemodialysis treatments. His labs in the ER were potassium of 5.3, urea nitrogen of 79 and creatinine of 12.05. The patient was admitted and received three hemodialysis treatments. He discharged.  

In the clinical records submitted for review, there was documentation that the patient had complaints of nausea/vomiting, diarrhea and chest pain. His EKG was normal, troponin was at baseline and CPK was normal. MCG for chronic renal failure lists clinical indications for admission to inpatient care as hemodynamic instability, severe infection not treatable in an outpatient setting, unexplained syncope, uremic symptoms such as pericarditis, pleural effusion, nausea, vomiting that is severe or persist despite observant care treatment, i.e., dialysis. The MCG guidelines for admission to general care include significant uremic complications as evidenced by outpatient therapy was ineffective or not feasible due to severe heart failure, severe hypertension, pleural effusion, pericarditis or pericardial effusion, cardiac arrhythmias of immediate concern, vomiting that was severe or persistent, altered mental status, recurrent seizures, dialysis indicated before long-term access or ambulatory arrangements can be made.  Documentation did not support the presence of any of these indicators for this patient. The patient was treated with dialysis and his symptoms resolved. The dialysis the patient needed could have been performed at a different level of care, such as observation.

Therefore, the request for inpatient hospital admission from is not considered medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Issue under review: Continued inpatient admission

Determination:
The continued inpatient admission was medically necessary.

The continued detoxification treatment of this patient's substance use disorders did require the continued structure of an inpatient level detoxification setting and monitoring. The patient's history of substance abuse (frequency and quantity) together with the drug-infested social environment 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; the patient was at high risk for treatment failure if detoxification and withdrawal management were to have been attempted and continued at a lower level of care. The patient had deficient coping skills, significant withdrawal symptoms that persisted, and clearly could not have completed or sustained a detoxification treatment episode at a lower level of care, especially in view of the past treatment history with relapses despite prior treatment with detoxification and rehabilitation treatments. 

Therefore, given the above, 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 with New York State instruction for medical necessity reviews including the application of the NY OASAS LOCADTR 3.0 Tool (referenced below) that requires the patient in this scenario default to the higher level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient with cocaine and alcohol use disorders was admitted to an inpatient detoxification unit.  The patient complained of tremors, insomnia, anxiety and irritability.  On initial physical exam the patient was noted to have bilateral tremors in hands and appeared anxious.  Blood alcohol level was negative, which is consistent with report of when last drink was.  Urine was positive for benzodiazepines and cocaine.  The health plan's determination is upheld.

The patient reported a history of alcohol and cocaine use disorder and denied any recent inpatient detox admissions.  There was no documented history of severe withdrawal.  The submitted chart is lacking in documentation of medical decision-making around the admission decision and continued stay.  The admission LOCADTR submitted by the facility indicated the patient was at risk for moderate withdrawal and does not have supports for early recovery.  His initial CIWA of 12 is suggestive of mild withdrawal. However, CIWA findings need to be correlated with the clinical presentation.  This patient endorsed having used cocaine that same day and several signs and symptoms of cocaine intoxication overlap with findings in alcohol withdrawal.  There was no documentation that discussed this.  Overall the charting does not document that the patient was in moderate withdrawal or required this level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Detoxification
 
Treatment: Inpatient Substance Abuse Services

The insurer denied the Inpatient Substance Abuse Services. 
The denial was reversed. 

This is a male patient who was admitted to this inpatient substance detoxification treatment in this hospital in late 2018 for detoxification from alcohol and substances. He had withdrawal symptoms including sweats, diarrhea, nausea, teary eyes, anxiety, irritable mood, abdominal and joint pain, sleeping problems, and tremors. He had a long history of alcohol and substance abuse. His toxicology was positive for opiates. He had multiple past inpatient substance detoxification and rehabilitation treatments. He was homeless, lacked a sober support system and coping skills, and could not maintain abstinence on his own. He also had reports of bipolar disorder. He was started on Librium and took two doses during this admission. He left against medical advice (AMA).

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report 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 consuming large amounts of alcohol and substances daily; therefore, he was at risk for severe, complicated and life-threatening withdrawal. 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. This was evidenced by the fact that he continued to use large amounts of alcohol and substances despite multiple past inpatient substance detoxification and rehabilitation treatments. This put him more at risk medically and psychiatrically and interfered with his functioning. He was homeless, lacked a sober support system and coping skills, and could not maintain abstinence on his own. He also had co-morbid bipolar disorder. He required and needed detoxification medication to modify withdrawal, as he was in active withdrawal with a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score of 15. He needed 24-hour medical inpatient hospital treatment for safe detoxification as he was at risk for worsened withdrawal symptoms if not in this 24-hour setting .

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

Diagnosis: Rhabdomyolysis, chronic open wound, past medical history significant for hypertension, chronic lymphedema, morbid obesity, and venous insufficiency

Treatment: Inpatient admission, diagnostic evaluation and medication management.

The insurer denied the inpatient admission. That denial was reversed

The patient presented to the emergency department following a mechanical fall.  The patient was apparently on the ground at home for three days. The patient was admitted for rhabdomyolysis, and possible urinary tract infection/sepsis. She was empirically started on intravenous antibiotics (vancomycin and Zosyn). The patient was also noted to have a chronic open left lower extremity wound for three months. The ulceration had foul - smelling discharge. She received intravenous fluid for the rhabdomyolysis. CT angiogram was negative for pulmonary embolism. The patient was refusing BiPap and was evaluated by psychiatry. CPK was trending downwards. The patient improved clinically, remained afebrile, hemo-dynamically stable, and was discharged to continue management as an outpatient.

Although she was afebrile, the patient was tachycardic (HR-123) with multiple laboratory abnormalities including elevated WBC (17.3), anemia, elevated CPKs (1017), elevated liver transaminases, and hyperglycemia. Additionally, the chronic leg ulcer was described as having "foul-smelling discharge." She required intravenous hydration for acute rhabdomyolysis, intravenous antibiotics for possible infection, as well as psycho-social intervention for many of her complex acute on chronic medical issues.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Issue under review: Inpatient admission

Determination:
The inpatient admission was medically necessary.

The patient meets the initial criteria for IV treatment and admission for cellulitis/abscess given by the Infectious Diseases Society of America (1), as he had systemic signs of infection (elevated WBC count). Initially, there was also concern that he may have had a deeper infection (gangrene), and thus IDSA guidelines and standard of care would dictate admission and close observation. Thus, this admission was warranted, supported by IDSA guidelines, as well as standard of care. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Periodontic compromise:
Issue under review: Dental implants

Determination:
The dental implants are medically necessary.

If the patient's remaining few teeth are periodontally compromised, as is being asserted, then dentures (full) are a treatment modality. This patient has poor bone structure as well as a gag reflex.  The poor bone structure will compromise the stability of the dentures, and with a gag reflex, the patient probably would not be able to tolerate them at all.  Having implants placed to stabilize the denture means the dentures can be less bulky, and therefore his gag reflex will hopefully be under control.  The proposed treatment is medically necessary from a dental standpoint.
Appeal type: Medical necessity
Decision: Overturned in Part

The patient has a past medical history significant for bipolar disease who presented with worsening frequency of rectal prolapse and incontinence. Of note, the patient was also facing eviction from her apartment due to cleanliness issues related to the incontinence. The prolapse was reducible but there was no surgeon at that hospital capable of addressing the rectal prolapse so she was transferred for higher level of care. Patient was evaluated by surgery who initially recommended outpatient surgical intervention. Patient then stated she was suicidal which required involvement of psychiatry who recommended inpatient hospitalization with 1:1 sitter due to harm to self and inability to care for herself in the community.

The health plan's determination is overturned in part. The inpatient stay was medically necessary until 1/25/19 (day of surgery) due to due to a psychiatry hold for potential to harm self with 1:1 sitter. The patient had complex social and mental health issues which required fixing the rectal prolapse prior to surgery as well as involvement of psychiatry and 1:1 sitter due to concern for harm to self.

However, from 1/25/19 forward, the patient's care could have been provided at a lower level of care (e.g. pain control, diet advancement after robotic rectopexy, as well as resolution of social issues so patient could be discharged back to home). After surgery, the patient's diet was advanced and her disposition was determined with the assistance of social work and psychiatry. This did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic pelvic pain
Treatment: Lyrica
The proposed treatment, Lyrica capsules, is not medically necessary.
The patient had a history of chronic pelvic pain and had failed a number of modalities.  The patient had not failed the formulary alternative, Cymbalta.  Lyrica is not Food and Drug Administration (FDA) approved for chronic pelvic pain, although it has been used for numerous chronic pain conditions, and may be a reasonable alternative if formulary alternatives have first been failed.  This is not a continuation of therapy, as the patient has only taken samples. Given the above, the requested Lyrica is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal stenosis, vertigo with gait ataxia
Treatment: Increase in PCA services to 49 hours per week
The proposed treatment of an increase in PCA services to 49 hours per week is deemed medically necessary. 
This is a female with a history of chronic low back pain, secondary spinal stenosis and vertigo resulting in gait ataxia and frequent falls.  The recent tasking tool used to determine the number of PCA hours which the patient requires made several errors and incorrect assumptions including that the patient's needs are:  dressing one time daily and not changing her clothes at bedtime, using the restroom only during the daytime, eating only two times daily, not ambulating in the evening or needing assistance with bed mobility/ambulation in the evening/nighttime.  Rather, the patient's actual needs include - dressing/changing clothes two to three times daily, using the restroom both during the daytime, evening and nighttime, eating three to four times daily, needing assistance with ambulating in the evening and needing assistance with bed mobility/ambulation in the evening/nighttime due to her increased fall risk secondary gait ataxia and vertigo. 
For these reasons, the proposed treatment of an increase in PCA services to 49 hours per week is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left labial swelling, pain, redness
Treatment: Inpatient admission
The proposed treatment of inpatient admission is deemed medically necessary. 
This female patient presented to the ER for further evaluation/management of left labial redness, swelling and pain. Intake vitals were notable for febrile temperature of 103.7 F, tachycardic heart rate of 123 beats per minute but blood pressure was otherwise hemodynamically stable at 146/89 and pulse oximetry was non-hypoxemic on room air at 96%. Examination was notable for left external labial redness and tenderness but no other significant abnormalities noted. Laboratory testing was notable for leukocytosis with a white blood cell (WBC) count of 12.9 and hyponatremia with serum sodium of 129. 
The medical records indicate that this patient was admitted to the inpatient medical service where she received treatment with broad spectrum IV antibiotics along with supportive care including IV fluids and continued cardiac monitoring. She responded well to the prescribed therapies and was subsequently discharged in stable condition. 
Due to signs/symptoms of sepsis including significantly febrile temperature of 103.7 F, tachycardia of 123 beats per minute and leukocytosis with elevated WBC of 12.9, she was at an increased risk for adverse events including increased morbidity/mortality. 
For these reasons, this patient's care could not have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome.  Hence, the proposed treatment of inpatient admission is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health (Major Depressive Disorder)
Treatment: Radiology Services (Transcranial Magnetic Stimulation Therapy)

Summary: This patient had depressive symptoms, which worsened, including depressed mood, and had a diagnosis of Major Depressive Disorder-Severe-Recurrent.  She had diagnoses of Generalized Anxiety Disorder and Post-traumatic Stress Disorder (PTSD), as well.  She had a trial of an antidepressant, Wellbutrin XL from 2014-2017 and had only a partial response and had intolerable side effects reported.  She also had two past psychotherapy trials.  She was sensitive to medications.  The request was for transcranial magnetic stimulation therapy (TMS) treatment.

The insurer has denied coverage for transcranial magnetic stimulation therapy (TMS) treatment as not medically necessary.  The denial was reversed.

The Food and Drug Administration (FDA) approved Neurostar Transcranial Magnetic Stimulation Therapy for the treatment of depression in October 2008.  TMS therapy was cleared by the FDA in 10/08 and indicated for the treatment of major depressive disorder 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 current episode.  Neurostar TMS Therapy System was the largest multisite (23 centers) randomized sham controlled trial ever conducted with TMS therapy.  This was the principal study for the FDA's approval of transcranial magnetic stimulation therapy for major depressive disorders in 10/08.  In addition, the American Psychiatric Association (APA) Practice Guidelines for the Treatment of 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.  In this case, this patient had a documented diagnosis of Major Depressive Disorder which is an FDA approved diagnosis for TMS treatment.  She had tried and failed an antidepressant medication, as she reportedly took Wellbutrin (Bupropion) XL from 2014-2017 and had only a partial response and had intolerable side effects reported; therefore, she was considered a candidate for TMS treatment.  Wellbutrin is a dopamine norepinephrine reuptake inhibitor which is FDA approved for Major Depressive Disorder.  She took an adequate dosage and had an adequate duration.  The standard recommendation for TMS treatment is for 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 current episode.  This patient took Wellbutrin, so failing four antidepressants, or trying two different classes of antidepressant medications with two augmentation therapies is not considered standard recommendations for the treatment of TMS treatment.  She also had two psychotherapy trials without efficacy. The medical necessity is substantiated.