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

Diagnosis: Alcohol Use Disorder
Treatment: Continued inpatient admission 

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

The requested benefit of continued 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 together with cannabis that did warrant the continued inpatient level detoxification and withdrawal management and monitoring. Detoxification, as appropriate, 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 the patient struggled with mild withdrawal symptoms in the context of symptoms of depression, anxiety and insomnia, and with associated clinical features that included limited insight, impaired judgment and poor control of impulses. Thus, the continued adult inpatient stay and detoxification treatment of this patient's substance use disorders did necessitate the continued structure of an inpatient level setting with structure, supports, and 24-hour monitoring. The patient's history of substance abuse (frequency and quantity) together with the co-occurring psychiatric disorder, 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, 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 admission is clinically appropriate, medically necessary and warranted, and is therefore a covered benefit in this case scenario. 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 including ASAM Patient Placement Criteria and appropriate application of the NY State OASAS LOCADTR 3.0 Criteria, referenced below.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
 
Treatment: Inpatient substance abuse admission, medication, monitoring

The insurer denied the continued inpatient substance abuse services. The denial was reversed.

This male was admitted to inpatient substance detoxification treatment for substance detoxification treatment.  He had multiple withdrawal symptoms and had a Clinical Opiate Withdrawal Scale (COWS) score of 10.  He was using tens of bags of intravenous (IV) heroin daily with a four year history of use, multiple bags of IV cocaine with a four year history of use, and was using nonprescription Methadone 1-3 times over the past month.  He had four past inpatient substance detoxification and rehabilitation treatments. He had a disease of the liver, as well as depression and anxiety.  He had a five day Methadone protocol and was discharged with a recommendation for inpatient substance rehabilitation.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports 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 use of multiple substances and was at risk for overdose and severe withdrawal symptoms.  According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he required 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting. This was evidenced by his continued use of multiple serious substances in large amounts despite multiple past inpatient substance detoxification and rehabilitation treatments. He lacked coping skills to maintain abstinence and had difficulty identifying triggers for use.  He required and received detoxification medication to modify withdrawal from heroin.  If he were prematurely discharged from this detoxification, he likely would have relapsed and also been at risk for worsened withdrawal symptoms. 

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

The patient with  a past medical history of C1 esterase inhibitor deficiency who presented to the emergency department with complaints of sore throat, abdominal pain, and dysuria. These symptoms started gradually one day before the day of admission and became worse.
The patient stated that these symptoms were typical for his episodes of angioedema, which the patient  had experienced in the past on multiple occasions. In addition, he noticed swelling in the  hands.
At the time of initial evaluation, the patient denied fever, diarrhea, vomiting, dizziness, or loss of consciousness. The patient was unable to identify the trigger for this event.The health plan's determination is upheld in whole .The inpatient hospital stay was not medically necessary. Admission for a lower level of care was warranted. The requested health service/treatment of inpatient stay was not medically necessary for this patient at the acute inpatient level of care based on the relatively mild severity of the symptoms defined by lack of airway compromise or hemodynamic instability, and also based on the fact that the patient responded to treatment very fast, with complete resolution of the symptoms.
Even though the patient came to the hospital with signs of angioedema, the patient  did not have any clinical signs of a compromised airway, hemodynamic instability, respiratory distress, or any other clinical symptoms requiring intervention at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/ Severe Opiate Disorder

Treatment: Zubsolv 5.7-1.4 mg TAB SUBL

The insurer denied the Zubsolv 5.7-1.4 mg TAB SUBL. The denial was reversed.

This is a young male patient who was admitted to a rehabilitation facility for drug treatment. The patient has a history of Severe Opiate Disorder with opioid withdrawal, Lyme disease, cannabis dependence and hospitalization for a suicide attempt. The patient reports that he had used Suboxone (buprenorphine/naloxone) and that he could not tolerate the taste as it made him nauseous.  He stopped Suboxone one week prior to the request for Zubsolv 5.7-1.4 mg tablets sublingual. He stated that he had loose stools and nausea while stopping Suboxone with associated opioid withdrawal symptoms. He did not want to take the injectable Vivitrol. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that methadone, levomethadyl acetate (LAAM), buprenorphine, and buprenorphine/naloxone which is Suboxone are all medications used for the maintenance treatment of opiate dependence or for opioid withdrawal. In this case, this patient tried Suboxone and had side effects and intolerability; therefore, the request was for Zubsolv 5.7-1.4 mg tablets sublingual. The Food and Drug Administration (FDA) approved Zubsolv for maintenance treatment of opioid dependence in July 2013. Zubsolv is a sublingual tablet formulation of buprenorphine which is a partial mu opioid receptor agonist and also naloxone which is a kappa opioid antagonist. It comes in 5.7 mg-1.4 mg and can be used at either 5.7 mg-1.4 mg or 11.4 mg-2.8 mg and the recommendation is to increase or decrease it by 1.4 mg/.36 mg or 2.8 mg/.72 mg. This medication is used to help the patient in substance treatment or to level the suppression of opioid withdrawal. The patient preferred not to take intramuscular medication, as Vivitrol is intramuscular. He preferred a less restrictive form of medication which was the oral Zubsolv.

Based on the above, the medical necessity for Zubsolv 5.7-1.4 mg TAB SUBL is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

This a patient who underwent flatfoot repair of the left foot. The patient was admitted for management of post-operative pain and was discharged. The health plan's determination is upheld.
The patient was admitted for management of post-operative pain. The patient did not have any qualifying criteria for inpatient admission, such as complications of the surgical procedure performed, inability to take medications by mouth, medically unstable, uncontrolled bleeding at the surgical site or inability to eat or drink independently. The patient's blood pressure at the time of admission was 163/99, which is elevated and considered stage 2 hypertension.  However, this does not rise to the level of a hypertensive crisis, according to the American Heart Association's Hypertension Guidelines (2).  The patient already has a history of hypertension, although the medical records do not indicate what a baseline blood pressure is for this patient.  An elevated blood pressure would also likely be expected in a patient who is experiencing post-operative pain. The care provided to the patient could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a history of type 1 diabetes mellitus and chronic kidney disease (CKD), who had presented to the emergency department  for management of hypoglycemia. He had an episode of loss of consciousness at a grocery store. A blood glucose of 26 milligrams per deciliter (mg/dl) was documented by Emergency Medical Services (EMS). Glucagon and 50% dextrose were administered with improvement in the patient's mental status. The patient was afebrile and hemodynamically stable. The physical examination was significant for left lower extremity swelling. A review of laboratory data reveled leukocytosis with a left shift, microcytic anemia, elevated blood urea nitrogen (BUN) and creatinine, mild hyperkalemia, low serum bicarbonate with normal anion gap, hyperglycemia, mildly elevated troponin, and elevated alkaline phosphatase. electrocardiogram (EKG) interpretation was normal sinus rhythm and ST elevation probably due to early repolarization.
The health plan's determination is overturned. The intensity of monitoring required in the care of this patient supports the medical necessity for an inpatient level of care. Hypoglycemia is significantly higher in patients with CKD with or without diabetes, and patients with both conditions are at greatest risk. The etiology of an increased risk of hypoglycemia in patients with CKD is multifactorial: poor nutrition in patients with advanced CKD resulting in reduced glycogen stores, smaller renal mass with reduced renal gluconeogenesis, and decreased elimination of insulin and oral antidiabetic agents. Thus, oral hypoglycemic agents and intermediate- or long-acting forms of insulin are more likely to cause recurrent hypoglycemia in these patients. Also, treatment of hypoglycemia may have a shorter duration of action than many of the precipitating drugs, and patients who are successfully treated initially may require repeat doses of glucose.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 Diabetes Mellitus 

Treatment: Invokana (canagliflozin)

The insurer denied the Invokana (canagliflozin). The denial was reversed.   

This is a female patient who was evaluated at her doctor's office for complaints of consistent chest discomfort that did not worsen on exertion, bending or twisting. She was unable to determine if her pain was superficial or below her skin. The patient has a past medical history of Type 2 diabetes mellitus (DM) with neurological manifestation, insulin-requiring or dependent type 2 DM, hypercholesterolemia, hypertension, hypothyroidism due to Hashimoto's thyroiditis, diabetic polyneuropathy, anemia, dyspepsia, belching, bloating, weight loss, and bilateral carpal tunnel syndrome. The patient's most recent A1C was 8.1; she had been awaiting Invokana.

The medical literature notes that Invokana is a sodium-glucose co-transporter 2 (SGLT2) inhibitor indicated: as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus; to reduce the risk of major adverse cardiovascular events in adults with type 2 diabetes mellitus and established cardiovascular disease.  The documentation indicated that the patient did have a diagnosis of type 2 diabetes mellitus.  The patient's most recent A1C was 8.1.  The patient was utilizing Janumet, Invokana, and Lantus SoloStar insulin.  The patient did not have appropriate control of her HgbA1c with the current medications.  The patient had previously tried Janumet which contains metformin. Even with the medication Janumet, the patient's A1C was not controlled. Therefore, it would not be appropriate to trial additional metformin medications. Therefore, the Invokana (canagliflozin) would be considered for the patient.  The records do not show any contraindication to the patient utilizing the formulary options listed by the insurer; however, the records do indicate that the patient had no improvement with the use of Janumet, which contains metformin which is a formulary
medication.

The carrier's denial of Invokana (canagliflozin) should be reversed.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with history of hypertension, diabetes, and coronary artery disease (CAD) who presented to the hospital with a chief complaint of shortness of breath. He stated that his symptoms started eight hours prior to presentation. He had recently undergone cardiac cath lab placement of two cardiac stents. He also reported chest tightness but denied nausea and vomiting. In addition, there was confusion of acute onset while the patient was in the emergency department and he complained of blurry vision. A code stroke was called. Vital signs showed temperature 97.9 Fahrenheit, heart rate 116, respiratory rate 20, and blood pressure 154/100. On physical examination, heart was regular, breath sounds were normal, abdomen was soft. Labs showed white blood cell (WBC) count of 5.7, hemoglobin 14.3, platelets 263, sodium 138, potassium 4.0, and creatinine 1.23. Head computed tomography (CT) was negative for acute stroke. Chest x-ray was negative for pneumonia. The patient was admitted for shortness of breath, suspected acute coronary syndrome (ACS), and suspected cerebrovascular accident (CVA). The plan of care included cardiac enzymes, hypertension management, neuro checks, brain magnetic resonance imaging (MRI), check vitamin B12 and folate levels, aspirin, atorvastatin, cardiology consult, neurology consult, and continue other home medications. It was ultimately thought that his symptoms were attributable to Brilinta and there was also concern for underlying chronic obstructive pulmonary disease (COPD). He was started on a bronchodilator. Brain MRI was negative for acute stroke. He was discharged.

The health plan's determination is upheld.

The reason is that the patient had negative initial imaging on head CT, labs were stable, the symptoms were ultimately attributable to an adverse medication reaction, and there were no other acute abnormalities such as active seizures, infection, sepsis, vasculitis, or other acute abnormalities. The patient was hemodynamically stable and had a stable physical exam in terms of neurologic findings after the initial episode in the emergency. In addition, brain MRI was negative and there were no acute electrocardiogram (EKG) changes or significant evidence of acute ACS. The patient's treatment could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission

The proposed acute level inpatient care for the management of acute cholangitis and gram negative bacteremia was not medically necessary. 

The patient underwent ERCP and biliary stent exchange at the outside hospital a day prior for the management of biliary stricture secondary to primary sclerosing cholangitis (PSC). He was discharged from the facility on Cipro, by mouth (PO), for five days, and Fentanyl patch. He presented to the ED with severe abdominal pain, subjective fever and chills, and was diagnosed with ascending cholangitis and gram negative bacteremia secondary to E.coli. He was hemodynamically stable in the ED and had a low grade fever of 99.0F which resolved after he was treated with broad spectrum antibiotics. His abdominal pain was controlled with IV morphine and the nausea was controlled with IV Zosyn. He was seen by GI and the recommendation was transfer the patient to the tertiary care where the ERCP was done, for further management of ascending cholangitis possibly due to occluded biliary stent. The tertiary center was contacted and they accepted the patient for transfer. Given this clinical scenario, and the fact, that the patient remained hemodynamically stable and afebrile throughout the clinical course and did not require surgical intervention, he could have been safely and appropriately managed at the lower level of care during his hospital say.
Appeal type: Medical necessity
Decision: Upheld

The patient has human immunodeficiency virus (HIV) on antiretroviral therapy.  The physician reports a 15% weight loss with muscle wasting, weakness, despite compliance with antiretroviral therapy.  The physician has prescribed Serostim for this patient to treat HIV-related wasting.  Serostim (somatropin or growth hormone) has been approved for HIV wasting syndrome since at least 2003.  Based on the findings of 10 studies, GH axis treatments are effective treating HIV-associated lipodystrophy.  However, clinicians must decide whether the attributed benefits are clinically significant, considering the costs and potential risks of GH axis treatment.  Nutrition is an integral component of medical care for people living with human immunodeficiency virus (HIV)/autoimmune deficiency syndrome (AIDS) (PLWHA).  Nutrition assessment should encompass food insecurity risk, changes in body composition, biochemical indices, and clinical indicators of comorbid disease.  Side effects from current antiretroviral therapy regimens are less prevalent than with previous generations of therapy.  There is limited information on this particular case to justify the medical necessity of the medication at this time.  The information available does not indicate that the weight loss is recent or progressive; there is no mention of any nutritional efforts or nutritional consultation provided to improve weight and stamina, nor is there mention of medical work-up or laboratory tests to rule out other medical reasons for symptoms, such as thyroid disease, adrenal insufficiency, malignancy or infections, among others, that can be seen with HIV.  The health plan's determination is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status post stab wound

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was reversed.

This patient is a male patient who presented to the emergency room following a stab wound to the mid-abdomen with a switch blade.  The patient's vital signs were a pulse of 72, a blood pressure of 133/85 and the patient complained of pain at the site of the stab wound.  A CT scan of the abdomen and pelvis revealed hyper-attenuating fluid posteriorly in the pelvis, there was concern that the fluid may be blood, per radiology interpretation.  The patient was taken to the operating room and underwent a diagnostic laparoscopy for evaluation of the fluid in the pelvis revealed on the CT scan.  A small amount of fluid was in the pelvis, the surgeon noted no injury to the mesentery of the bowel or other organs and the laparoscope was withdrawn.  After being stabilized in the PACU, the patient was admitted to the surgical floor and was discharged that same day.

The Milliman Care Guidelines state that indications for admission to inpatient care for trauma are for surgical and postprocedural care.  The General Admission criteria include emergency procedures needed and abdominal abnormalities.  In the clinical records submitted for review, the patient presented to the ER after being stabbed.  He had a surgical procedure to evaluate the findings on CT. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient admission is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee Pain 
 
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) by emergency medical service with complaints of knee pain. It was reported that the patient had been to see her primary care physician and she was advised to go to the ED for further work up and pain management. She had a history of multiple sclerosis and chronic pain. She had an electrocardiogram (EKG) that was normal. She was evaluated by neurology. Her physical exam revealed diffuse mild pain with range of motion of the knee. She had a knee x-ray that was negative for a fracture or degenerative disease. She received oxycodone for her pain management. A magnetic resonance imaging (MRI) was ordered; however due to the patent's size it could not be performed. The patient was discharged home with aftercare instructions.

According to current literature a patient may be admitted to inpatient services when there is newly diagnosed or suspected bone, muscle, joint, orthopedic device infection, there is a fracture dislocation or there is evidence of severe vasculitis or severe rheumatologic disease.  Additionally, in a patient with chronic pain admission to inpatient services may be appropriate for patient when there is documentation supporting a failure of a lower level of care.  Within the documentation none of the above is present.  The documentation indicated the patient was admitted for a further work-up; however, the patient did receive 1 tablet of oxycodone while in the emergency department which resolved her pain.

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.