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

This is a patient i who presented to the emergency department (ED) with a left buttocks abscess. She had been seen by her primary care provider (PCP) twice prior to presentation to the ED. Both times pus was expressed from the abscess and the patient was started on oral clindamycin (no abscess culture was collected). In addition to the abscess, the patient had a fever with a maximum temperature (Tmax) of 102 degrees Fahrenheit (F). She was sent to the ED by the PCP for further management. The health plan's determination is overturned. The patient failed outpatient antibiotics and drainage. She was admitted to the hospital. She was febrile, which is concerning for a bloodstream infection, and she required intravenous (IV) antibiotics and inpatient level monitoring.
Appeal type: Medical necessity
Decision: Overturned

The patient has hearing loss.  The patient has difficulty hearing at community college classes.  An ear exam shows a retracted ear drum on the right with a small perforation.  The left ear shows a small perforation.  A hearing test shows a moderate mixed hearing loss.  Hearing test also shows a predominant conductive loss.  Binaural Hearing aids have been requested.  The hearing aids are medically necessary. 
The patient has moderate hearing loss that is amenable to hearing aid amplification.  There is no reasonable medical alternative.  It appears from the predominant conductive portion of the hearing test that surgery would be possible to help with the conductive component of the patient's hearing loss, but the patient would still have a sensorineural loss that would need amplification.  The request for hearing aids is considered standard of care.  Without hearing aids, the audiogram confirms that the patient would have a hard time hearing in most situations of life, to include current classroom work.  There are no nationally identified standards as to who the ideal hearing aid candidate is.  Most people who benefit from hearing aids have moderate to severe, bilateral hearing loss.  Current Medicaid indications vary by state, but most consider hearing aids necessary in patients with a 30-40dB (most consider 40dB the cutoff above 2,000Hz).  Given the results of the audiogram to include the speech discrimination scores, it is likely that this patient will receive a benefit from hearing aids.  The HP determination is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient presented to the ED with severe abdominal pain and nausea that started a night before admission. The pain was intractable, and more in the left lower quadrant than right lower quadrant. She had been seen four weeks prior by her PCP for lower back pain and lower abdominal pain. She had been prescribed antibiotics, but then was told by her PCP to stop the medication, as the pain did not improve better. She also c/o four-day h/o sore throat, hoarse voice, paranasal sinus pain with productive cough, pain around right forehead, and face. She was febrile with fever of 101-102 during her hospitalization, which as per ID consultant, was due to upper respiratory tract infection with sinus infection. Her CT scan of the abdomen and MRI abdomen were normal except for a liver hemangioma. The pelvic ultrasound was normal. She did have mild elevation of liver function, which trended down over the next 48 hours. The hepatitis serology for A, B, C were sent as per the evaluation for abnormal liver function tests. The GI and Gyn consultants evaluated the patient, and the recommendation was to manage the patient with supportive care with IV fluids, antiemetics, and pain control. 

The patient was able to tolerate clear liquid on day one, and her diet was advanced as tolerated. She remained hemodynamically stable throughout her admission, and was empirically treated with Ceftriaxone for possible sinus infection. In view of this clinical scenario, she could have been safely and appropriately managed at the lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient has a personal history of skin cancer.  The provider requests coverage for confocal microscopy to evaluate a lesion on the right pretibia.  The subject under review is whether the reflectance confocal microscopy is likely to be more beneficial than any standard treatment for this patient's condition.  The health plan's determination is upheld.

No, reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of the skin is not likely to be more beneficial than any standard treatment for the patient's condition.
Although the technology shows real promise, further work is needed to determine the best way to integrate the technology as a standard of care.  The mastery of RCM requires extensive training to recognize and become familiar with the normal and abnormal imaging patterns.  A barrier for the adoption of RCM is that training opportunities are limited.  In the United Kingdom (UK), National Institute for Health and Care Excellent (NICE) guidelines state there is insufficient evidence to recommend the routine use of RCM in deciding whether to biopsy cutaneous lesions and to map margins of cutaneous tumors.  In the United States, the consensus is that further studies are warranted, as access to training in this procedure is not readily available.  Also, it is not clear how the results of such testing can improve the overall health outcome.  Therefore, at this time, the use of RCM would not be considered the standard of care.  It is not likely to be more beneficial than any standard treatment for the patient's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient has a suspicious nevus of the right pretibial skin.  Reflectance Confocal Microscopy was performed that was suggestive of a dermatofibroma.  The clinic note that documented the confocal imaging recommended a shave biopsy to evaluate the deeper aspects of the lesion and confidently exclude neoplasm.
The subject under review is whether reflectance confocal microscopy for imaging of the skin is likely to be more beneficial than any standard treatment in this case.  The health plan's determination is upheld.

Although Reflectance Confocal Microscopy (RCM) can help diagnose a given skin lesion, a physical examination by a trained dermatologist and (if so indicated) a skin biopsy to rule out atypia or malignancy remains the gold standard as per all modern dermatology literature reviews.  The clinic note referenced the need to do a biopsy if diagnostic confirmation was indicated.  Outcomes of RCM versus clinical and skin biopsy evaluation do not, as per current standards of care, obviate the need for a clinical evaluation, confirmation of any changing in size or shape from the patient in a standard history, and a biopsy, if so indicated, to rule out malignancy.

RCM might or might not help determine if a biopsy is needed, but medically the indication for a biopsy in a potentially atypical or malignant lesion based on history and/or visual examination is not precluded by any RCM findings that show any benign appearance.  Only a skin biopsy can reliably and conclusively diagnose any benign, atypical, or malignant biological behavior of a given skin lesion that is of clinical note for any malignant risks.

Accordingly, RCM is not more beneficial than a standard history, clinical evaluation, and (if indicated) a skin biopsy for histological confirmation to achieve diagnostic, treatment, and outcomes when evaluating and treating for a potential skin cancer.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient has a suspicious lesion to right shin, which was evaluated by confocal microscopy and felt to be a dermatofibroma, but a more worrisome lesion could not be excluded.  The subject under review is whether the use of the reflectance confocal microscopy for cellular and sub-cellular imaging of the skin is likely to be more beneficial for this patient's disease.  The health plan's determination is overturned.

Biopsy and histologic evaluation have been the gold standard to diagnose skin tumors. Reflectance confocal microcopy (RCM) is a noninvasive, innovative diagnostic technique that enables visualization of different skin layers at an almost histologic resolution.  RCM has been proven beneficial in management of various cutaneous lesions. This prevents unnecessary biopsies.  Current literature supports use of RCM.
A recent review compared dermoscopy and confocal microscopy.  Eight published studies were included in the analysis, involving 1141 skin lesions, which reported a per-lesion analysis of dermoscopy and RCM.  Within the same patient group and at the per-lesion level, RCM significantly increased the detection rate of malignant skin tumours by 7.7% (95% confidence interval [CI] 0.01-0.14).
RCM imaging combined with dermoscopic examination is guiding the triage of lesions into those that appear benign, which are being spared from biopsy, against those that appear suspicious, which are then biopsied.  Current evidence supports that RCM prevents unnecessary biopsies.  Therefore, given the evidence based literature support for use of confocal microscopy to evaluate skin lesions in order to determine whether a biopsy is necessary, the use of confocal microscopy is more likely to be beneficial than other standard treatments.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the hospital with complaints of being less active, having trouble swallowing and having difficulty with his gait. He had a history of recently diagnosed multiple sclerosis when he presented with a left parietal tumor that was found to be demyelinating. 
The health plan's determination of medical necessity is upheld.
A head CT scan revealed no acute changes. The patient otherwise did not have any progressive neurological signs or symptoms. There was a low suspicion of stroke. There was no evidence of any hemodynamic instability. His Depakote level was slightly supratherapeutic but was not believed to be causing any symptoms. He did not require any any neurochecks. He did not require any hemodynamic, cardiac, pulmonary or other medical monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mastitis, postpartum 
 
Treatment: Inpatient admission, diagnostic evaluation, medication management.

The insurer denied inpatient hospital stay. That denial was upheld.
This patient presented to the Emergency Department with complaints of fever as well as breast pain.  The patient was approximately 5 weeks postpartum at 35 weeks gestation.  The daughter was diagnosed with thrush the prior week.  She was breast-feeding and began having breast pain 5 days prior.  She was placed on topical clotrimazole 3 days prior to presentation for suspected candidal infection.  The patient states that since then the pain and swelling had worsened and she developed fever.  The physical exam revealed a temperature of 99 degrees with a heart rate of 110 bpm.  Her blood pressure was 117/75.  The patient was well-nourished on exam.  There was tenderness to palpation to both breasts.  There was no active nipple drainage.  It was recommended the patient undergo laboratory studies and be given IV fluids as well as oral Tylenol.  The patient's laboratory studies revealed a lactate at 2.0 with a white blood cell count 19.24.  The patient did undergo a chest x-ray revealing a normal study.  The patient was diagnosed with mastitis and recommended to be admitted to rule out sepsis.  The documentation detailed the patient continued with treatment to include intravenous (IV) Ancef.  She did have improvement with treatment and no further adverse events.  She was discharged on oral Keflex.

According to current literature a patient may be admitted when there is a need for surgery or other inpatient monitoring.  Furthermore, admission may be appropriate in relation to sepsis if there is evidence of hemodynamic instability that is not readily corrected by appropriate observation treatment, bacteremia, hypoxemia, severe or persistent altered mental status is present, there has been a failure of outpatient treatment or there is severe persistent dehydration.  

Within the documentation it was noted the patient presented with a high likelihood of mastitis.  The patient was approximately five weeks postpartum and had subjective complaints of fever as well as breast pain.  The patient had an elevated white blood cell count and slightly elevated lactic acid.  However, there is a lack of documentation to support the patient failed lower levels of treatment within the observational level prior to admission into the inpatient level of care.  Therefore, while the patient may have needed an initial observation stay it does not appear the inpatient admission was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol dependence
Treatment: Continued inpatient detoxification
The proposed treatment, continued inpatient detoxification, was medically necessary for this patient.
The requested benefit of continued 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 cocaine that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring.  Detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission.  Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms (tremor, sweats, nausea, anxiety, irritability, restlessness and insomnia) which were being effectively addressed with Librium and supportive measures.  The patient had associated clinical features that included 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 necessitate the continued structure of an inpatient level setting with withdrawal management and psychosocial supports and 24-hour monitoring.  The patient's history of substance abuse (frequency and quantity) together with the 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 continued 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.  Thus, the requested benefit is not excluded under the plan and should be covered in keeping with prevailing standards of care pertaining to substance use disorder services.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiomyopathy, past history of hypertension, diabetes mellitus, and sleep apnea
 
Treatment: Inpatient admission, diagnostic evaluation and medication management

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

The patient had a past medical history notable for non-ischemic dilated cardiomyopathy, ejection fraction 30%, and was admitted for elective pacemaker lead extraction and replacement. There were no complications.  Following the procedure completed on the morning the potassium (K) was 6.2 and later 6.6 at 17:27.   He was treated, and rechecked at about 2200 at that time the K was 6.1.  The following day at 0623 K was 6.4-slightly hemolyzed. There were no arrhythmias. EKG showed a right bundle branch block. The patient was discharged home.  

Inpatient admission status is not medically necessary, per 22nd Edition MCG Guidelines for Cardiovascular Surgery or Procedure GRG: SG-CVS (ISC GRG). For uncomplicated pacemaker lead extraction and revision, this is considered an elective outpatient procedure, with up to 1 night of observational status hospital monitoring permitted. There were no post-operative complications, such as bleeding or infection, nor any enduring clinical or hemodynamic instability after the initial intervention. There was no evidence of procedurally-related pneumothorax. The patient did not require an acute inpatient admission.  He could have been managed during observation which would have allowed for the monitoring of the potassium.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol abuse
Treatment: Inpatient admission
The proposed treatment, inpatient admission, was not medically necessary for this patient.

The proposed inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care in a less restrictive setting with appropriate monitoring and supervision and structure. The treatment with detoxification of this patient's substance use disorder did not require the structure of an inpatient setting. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk to self or others, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. There were no severe symptoms of withdrawal or biomedical issues in this case, and no history of withdrawal seizures or delirium tremens. Moreover, the patient had received detoxification treatment that had concluded the week prior to presentation including an admission to rehabilitation services with discharge date unknown. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with a past history of multiple substance use disorder treatment episodes. Thus, admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.

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 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, 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. There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had just received detoxification services in the week immediately prior to presentation. Thus, admission for acute inpatient level detoxification treatment, and the other requested inpatient level services were not medically necessary in this case scenario, as the health plan asserts. And, NY State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below, are not met for the 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, the American Society of Addiction Medicine (ASAM) Criteria and published guideline.
Appeal type: Medical necessity
Decision: Upheld

The patient was admitted to inpatient level services for treatment of cannabis use disorder; the patient had been using up to 5 blunts of marijuana per day in violation of his parole. The patient was referred for substance-related treatment after testing positive for tetrahydrocannabinol (THC) while in outpatient treatment. Thus, the referral to inpatient level substance use disorder treatment was mandated due to the probationary legal status (parole), and ongoing problems with maintaining abstinence from cannabis use. The patient was externally motivated to enter substance abuse rehabilitation treatment.

The health plan's determination is upheld. The structure and intensity of services necessary for a successful rehabilitation/substance use disorder treatment could have been effectively provided at a lower level of care in a less restrictive treatment setting with sober supports. There is no evidence that inpatient level structure and 24-hour monitoring is medically necessary for a successful outcome. And, there were no biomedical, psychiatric or general medical issues that warranted the admission and the continued inpatient level treatment.