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

Diagnosis: Left knee pain from Osteoarthritis (OA)

Treatment: Euflexxa injections x3 code J7323-Hyaluronan or derivative Euflexxa, for intra-articular injection

 The insurer denied coverage for Euflexxa injections x3 code J7323-Hyaluronan or derivative Euflexxa, for intra-articular injection. The denial was upheld.

This patient is a male, diagnosed with left knee pain from Osteoarthritis (OA). Magnetic Resonance Imaging (MRI) report of the left knee revealed a flap tear of the anterior horn of the lateral meniscus, as well as, a horizontal under-surface tear at the posterior horn, moderate-sized joint effusion, and mild osteoarthritis. X-ray report of the left knee revealed mild lateral patellofemoral arthritis, and small spur at the tibial tuberosity. The patient presented for follow-up evaluation with complaints of left knee pain. A physical examination of the left knee revealed trace joint effusion. Active range of motion was 0-120 degrees. There was mild lateral joint line tenderness. The consulting physician contends the best treatment option for the patient is Euflexxa. He adds that the patient was successfully treated with Euflexxa in the past. Therefore, medical necessity has been established for the requested left knee Hyaluronan or derivative, Euflexxa, for intra-articular injection and this request is certified.

According to the American Academy of Orthopedic Surgeons, The 2013 osteoarthris (OA) knee treatment clinical practice guideline (CPG) contains one significant recommendation change from the 2008 CPG, and this is with regard to the issue of viscosupplementation. The 2008 OA knee CPG included an "inconclusive" recommendation regarding the use of intra-articular hyaluronic acid (HA) injections that was largely the motivating factor for the expedited update of the CPG. The second edition CPG recommendation reads "We cannot recommend using hyaluronic acid (HA) for patients with symptomatic OA of the knee," with a "Strong" rating, based on supporting evidence from 3 high-quality and 11 moderate-quality research studies that met the inclusion criteria.

The work group understands the potential impact that this recommendation could have on clinical practice. Nonetheless, the CPG's best evidence synthesis does not support the efficacy of viscosupplementation. Although statistically significant outcomes were seen in some studies with higher molecular weight HA preparations, these outcomes were not clinically significant, based on a lack of minimum clinically important improvement (MCII). (For more information on MCII, see "The Importance of Clinical Significance in AAOS CPGs," AAOS Now, May 2013.)The Orthopedic group reports "strongly do not recommend use." 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. The denial is consistent with current practice.

Based on the above, the medical necessity for left knee Euflexxa injections x3 code J7323-Hyaluronan or derivative, Euflexxa, for intra-articular injection is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bacterial Cellulitis or Erysipelas

Treatment: Inpatient Admission

The insurer has denied coverage for inpatient admission. The denial was upheld.


The history was that patient had walked for a long time in the museum on a school trip with soaked sneakers. He came home and showed his family his white wrinkly skin when he took them off. He woke up the next morning when he reported that his feet were painful especially when he tried to walk, and he did not want to bear weight on either foot. The history and physical notes that there was no injury to the area, He had on examination edema of both feet (mostly on the soles) with erythema, tenderness and warmth to touch. Capillary refill was normal there were no compromise of the vascular system and no neurologic deficits. There was no calf tenderness or swelling to suggest myositis, which could be seen after prolonged exertion, especially walking or running. He had full range of motion at the ankle joints and there were no skin lesions or breaks. The exam also notes that the area of erythema of bilateral plantar aspect of the feet was well demarcated and that the edema was non-pitting. He was otherwise well appearing and not in distress or toxic.
 
His labs were within normal limits except for rapid group A strep test positive (which could be prior carriage) and the only abnormal lab test was for a slight neutrophilic predominance, which can be caused by any stress reaction of the body. Both ankles had full range of motion, there were no breaks or lesions on the skin, he was otherwise well appearing and non-toxic, and his vital signs were stable. Importantly, there was no evidence of streptococcal of staphylococcal infection as evidenced by physical exam and laboratory evaluation. In fact, there was no portal of entry for these bacteria. 

He was admitted for antibiotics, but this does not seem to have been warranted. The diagnosis of bacterial cellulitis or erysipelas seems erroneous. Neither of these conditions commonly present with bilaterally symmetrical involvement. Instead he had pressure and cold injury to the soft tissues of his soles (it was mid-December) that needed to be treated with rest and pain medications. He received intravenous antibiotics and improved but this improvement would be expected without antibiotics; instead, he a mild case of trench feet. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic endometrial cancer and confusion
 
Treatment: Inpatient admission

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

This female patient had a history of metastatic endometrial cancer and had refused further chemotherapy.  The patient was sent to the clinic for confusion over the past 2 weeks, forgetfulness, and word-finding difficulty.  The patient's past medical history included hypertension, hyperlipidemia, diabetes mellitus, lower extremity deep vein thrombosis, epilepsy, and chronic low back pain due to disc herniation. Examination revealed a blood pressure of 135/80, respiratory rate of 18, pulse of 70 and oxygen saturation was 98% on room air.  The patient was alert and oriented partially to person, place, and time.  Strength was rated 5/5.  The patient had no asterixis.  She was admitted for altered mental status x 1 month.  CT scan of the head and MRI of the brain revealed no metastases, acute infarct, or intracranial hemorrhage. The MRI of the spine revealed possible metastatic infiltration.  The patient was stabilized and discharged home.

MCG indicates that a hospital admission may be appropriate for a patient with altered mental status that is severe or persistent such as different from baseline and may include a confused state with disorientation or difficulty following commands for more than a few hours despite appropriate treatment. Admission would also be appropriate for patients who have a new onset severe neurologic finding.  The records indicated the patient had a confused state for 1 month. On admission, the evaluation indicated the patient was awake, alert, oriented to person, place, and time.  Her speech and memory were intact.  The next day it was reported the patient was aware of time, place, and person, but made inappropriate comments and had declining memory.  The records failed to support the patient was not appropriate for outpatient evaluation or that she was inappropriate for observation. 

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
 
Treatment: Inpatient substance detoxification treatment

The insurer denied continued inpatient detoxification treatment. The denial was reversed.

This is a female who was admitted for inpatient substance detoxification treatment. She was experiencing multiple withdrawal symptoms. She presented with a Clinical Opiate Withdrawal Scale (COWS) of 10. She had a positive toxicology for opiates, cocaine, and OxyContin. The patient had a past reported inpatient substance rehabilitation. She was using multiple bags of intravenous (IV) heroin per day with a 10 year history, crack per day with a 12 year history, and OxyContin tablets per day with a one year history. She was discharged to substance residential treatment after 5 days of treatment.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders indicates 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.

This patient used multiple substances and was at risk for death from overdose and severe withdrawal if not detoxified completely.  According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) she required 24-hour treatment for an inability to be safely and effectively treated for detoxification in a less restrictive setting, as she continued to use substances despite past inpatient treatment, and due to need for detoxification medication to modify withdrawal and prevent worsened/severe withdrawal symptoms. She had reported withdrawal symptoms and COWS of 6 during the denial period, and still required and received detoxification medication. It was necessary to get inpatient detoxification treatment prior to inpatient substance residential treatment, and she could not successfully be detoxified in an outpatient setting.  

The carrier's denial of coverage for the continued inpatient detoxification is reversed. The medical necessity for continued inpatient treatment is substantiated.
Appeal type: Medical necessity
Decision: Upheld

The patient  received inpatient substance abuse treatment . The patient had reported using 11 bags of heroin daily, smoking cocaine weekly with last use the night prior, and drinking approximately 1 pint of vodka daily with the last used being the night prior. The last detoxification admission was two months prior. Clinical history was negative for psychiatric hospitalizations or suicide attempts. There is no evidence in the clinical documentation of any unstable medical or psychiatric problems. Liver enzymes were elevated consistent with chronic alcohol use. Vital signs were generally unremarkable during admission though with a couple of briefly elevated pulse rates. The patient reportedly left the hospital before completing treatment when  found in the shower with another patient and asked to leave. Patient  denied withdrawal symptoms on admission and denied psychotic symptoms.
The patient did not require immediate hospitalization due to a life-threatening medical condition or severe psychiatric crisis. Patient was not in full remission from a substance use disorder. Patient was taking substances with a risk of medical complications from withdrawal. The patient did not have serious medical or psychiatric problems that needed inpatient treatment. The patient was not using in amounts or frequencies leading to imminent risk of harm. The patient had no documented interpersonal deficits. The patient did not exhibit predatory behavior. There were no documented strong cravings or any behavioral instability. There is no documentation indicating that the patient could not handle triggers. . Clinical documentation does not establish  having severe withdrawal symptoms requiring 24 hour care with the availability of nursing and medical treatment. 
The Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Level of Care is: Rehabilitative Services in a Residential Setting. Inpatient substance abuse was not medically necessary.
The health plan determination is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's disease
Issue under review: Stelara

Determination:
The Stelara is not medically necessary.

The patient has moderate to severe Crohn's and has failed treatment with Humira. The plan-preferred agent when patients have failed anti-TNFs (tumor necrosis factor) is Entyvio. The patient's MD is requesting Stelara. While Stelara is safe and effective treatment for Crohn's, Entyvio is also a safe and effective regimen in patients such as this. While the MD states that Stelara is a more effective option, as noted by Singh in the reference below, patients who discontinued prior anti-TNF due to a loss of response were 27% less likely to achieve remission with induction therapy with second-line biologics, particularly to Stelara. There was no difference in response to Entyvio in patients with prior loss of response to anti-TNF agents.

Therefore, as Entyvio and Stelara are both safe and potentially effective options in patients with Crohn's who have lost response to Humira, the proposed Stelara is not medically necessary, as the preferred agent is Entyvio, and the health plan acted reasonably and with sound medical judgement by denying the Stelara in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Inpatient admission
The Inpatient admission was medically necessary for this patient.

The requested benefit of Inpatient admission 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 cannabis that did warrant inpatient level detoxification and withdrawal management and monitoring. The patient's environment was not conducive to an effective detoxification, and the patient struggled with withdrawal symptoms initially with continued risk for withdrawal symptoms. The patient displayed limited to fair insight, impaired judgment and poor control of impulses with regard to the substance use disorders together with co-occurring symptoms of anxiety and history of schizophrenia and depressive disorder.

Thus, the adult inpatient stay for detoxification treatment of this patient's substance use disorders did necessitate the admission and the continued structure of an inpatient level setting with 24-hour monitoring. The patient's history of substance abuse (frequency and quantity) together with the co-occurring psychiatric disorders do reflect the seriousness of the substance use disorder, and the co-occurring disorders that served to trigger the patient's substance use. Again, the clinical features and treatment dimensions in this case do warrant and support 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 or falls if detoxification and withdrawal management were to have been 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, ASAM Criteria, and the scientific literature, referenced below, and consistent with New York State instruction for medical necessity reviews including the appropriate application of NY OASAS LOCADTR 3.0 Criteria.

The requested benefit of Inpatient admission is clinically appropriate, medically necessary and warranted, and should therefore be covered in this case scenario. The Substance abuse detoxification with inpatient level treatment through discharge could not have been safely or effectively provided with lower level services, as noted above. Thus, the requested benefit should be covered in keeping with prevailing standards of care pertaining to the substance use disorder services, including ASAM Criteria and the application of the NY State OASAS LOCADTR 3.0 Criteria, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Inpatient Admission
The insurer denied the Inpatient Admission. The denial was upheld. 
This is a female patient who presented to the Emergency Department (ED) in early 2019 with complaints of shortness of breath for four days, worsening cough, chills, malaise, and fatigue. She denied fever or chest pain.  The patient had a history of osteoarthritis, asthma, bronchitis, back pain, and smoker. The patient reported that she had recently been treated with a Z pack for urinary symptoms. She was evaluated by Infectious Diseases and Pulmonology. Her treatment included intravenous steroids, bronchodilators and antibiotics. She was switched to oral medications and discharged home when medically stable with follow-up in outpatient.   

The patient remained stable and could have been switched to oral antibiotics and steroids and bronchodilator and discharged home with follow-up in outpatient.  Pneumonia, if present, was mild.  More likely there was some atelectasis given that the patient was afebrile and white blood cell count was normal.  In any event the patient's pneumonia severity index (PSI) was low CURB 65 score was Zero.  

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

Diagnosis: Right renal colic
Treatment: Inpatient stay 

Summary:

An acute inpatient level of care was not medically necessary.  Care could have been provided at a lower level of care. The patient was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis.  Following admission, there were no unstable vital signs reported.  She did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. She did not have bilateral obstruction, acute renal failure, severe vomiting.  Pain control, IV antibiotics and IVF followed by stent placement in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a history of (h/o) attention deficit hyperactivity disorder (ADHD), developmental delay and asthma who presented with a complaint of abdominal pain, vomiting and apparent syncopal episode with head trauma.  His mother states he woke up with abdominal pain.  He ate breakfast and vomited multiple times.  The patient then became more lethargic and fell over and hit his head on the ground.  He was shaking, slowly, per his mother, and he wasn't normal for 20 minutes, per mother.  The shaking was slow and rhythmic of the right side of his body, and he was unresponsive with eyes rolling back.  The rhythmic movements lasted approximately 2 minutes, and afterward he was unresponsive with slow breathing and skin pallor for about 10 minutes while waiting for Emergency Medical Services (EMS).  The plan was for an electroencephalogram (EEG), neuro checks and close monitoring.  A computed tomography (CT) scan was performed and showed no acute intracranial pathology.  The EEG showed abnormal findings with characteristics of benign focal epilepsy.  Pediatric Neurology consulted and recommended an outpatient magnetic resonance imaging (MRI) scan, as the patient was back to baseline.  They also recommended neurology follow up. 
The health plan's determination is overturned.  Admission with a plan for EEG and Pediatric Neurology consultation would be the standard of care given his prolonged altered mental status.  In the event this patient developed status epilepticus, emergent care including intravenous (IV) antiepileptic medication and close monitoring, sometimes in an Intensive Care Unit (ICU) setting would be required.  Respiratory support may also be required after multiple doses of IV antiepileptic medication.  This could only be accomplished expediently at inpatient level of care.  For these reasons his admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness; vertigo
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient's NIH stroke scale score was zero at presentation. He had a normal neurological examination. His MRI was negative for stroke. The duration of his symptoms was not consistent with TIA (transient ischemic attack).   The neurological consultation, diagnostic studies, monitoring and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient has diagnoses of Borderline Personality Disorder (BPD). Binge Eating Disorder (BED), Body Dysmorphia Disorder (BDD), Unspecified Affective Disorder (UAD) and passive suicidal ideation. Case notes document that the patient has a long past history of anxiety, depression, abnormal behaviors, excess emotional sensitivity, and bullying since middle school. The patient has a learning disorder (LD) and repeated the 9th grade. The patient has had only limited benefit from multiple past treatments at the Inpatient Psychiatric (IP), RT (residential treatment) level, and outpatient treatment. Prior to the RT dates being currently evaluated, the patient was discharged from IP within the prior month.

The health plan's determination is overturned. The Residential Mental Health Treatment was medically necessary. In addition of having high emotional reactivity and sensitivity, this patient reproduced his pre-admission abnormal behaviors and dysphoric moods (anxiety, depression) during the RMHT under review and had only very short periods of normal mood. The patient continued to refuse to engage in therapy, refused to fill-in therapeutically appropriate forms, and refused at times to get out of bed. The patient eloped and when apprehended was increased in the intensity of care by admission to inpatient hospital. In addition to aspects of mood dysregulation, abnormal eating and body dysmorphia, the patient appears to have exhibited strong features of borderline personality disorder (BPD), a chronic, and difficult to treat disorder in a person with low motivation, poor insight, and refractoriness to new learning. The choice of dialectical behavior therapy (DBT) as the major subtype of cognitive therapy was appropriate, but, unfortunately, was not effective in this admission to RT. It is possible that any one of this patient's diagnoses could be treated at the Partial Hospital level, but the combination of diagnoses and refractory history of unresponsiveness to past treatments would make treatment at the PH level inappropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fracture and laceration
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

This young boy sustained a high energy type trauma with involvement of head, soft tissue and fracture to leg. He required multiple service consultations. He required special testing and monitoring for head trauma. He was also found to require Plastic surgery closure to laceration. He required closed reduction of the tibia fracture, which was performed the following morning. Anesthesia for orthopedic reduction after immediate head trauma would not be appropriate.  There would be the risk of unrecognized head injury despite normal imaging. This young man also required IV analgesia secondary to his pain. The combination of service provided and extent of injuries substantiated the admission and length of stay.  These services could not be provided at a lower level of care.