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

Cardiac/Circulatory Problems/ other
Inpatient hospital

The patient is a female with a history of hypothyroid, and depression who was admitted after a syncopal episode. No history of similar episodes were reported. The patient was out running she then awoke in a ditch. She underwent a computed tomography (CT) of the head, serum lab work, as well as an electrocardiogram (EKG). She was admitted to the hospital and placed on fluid hydration. An Inpatient echocardiogram and stress test were completed prior to discharge to home. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient hospital stay was not medically necessary. Based on available data. there was no hemodynamic instability, fever, altered mental status that is severe or persistent, cardiac arrhythmias of immediate concern, significant respiratory findings, metabolic or electrolyte abnormalities that required inpatient level of care. The patient was tolerating oral intake and remained stable throughout the stay. The patient could have been managed at a lower lever of care.
Appeal type: Medical necessity
Decision: Upheld

Seizure
Inpatient hospital stay
The patient with a past medical history of seizures, hypertension, diabetes mellitus, alcohol abuse, astrocytoma which required frontal craniotomy and resection, and also a history of ventriculoperitoneal (VP) shunt, presented to the emergency department after a seizure. The patient reported aura followed by a seizure while in the bathroom. It was reported that while having a seizure the patient hit his head on the sink.
Per the history and physical exam report, the patient did not lose consciousness and had no urinary or fecal incontinence or tongue biting. Reportedly, while seen by the admitting physician, the patient was in stable condition and had no complaints. A review of systems was obtained on admission. It was negative. According to the history and physical exam note, the patient had a recent hospitalization.  During that previous admission the dose of seizure medication, Keppra was increased to 1250 milligrams (mg) twice a day. It was reported that, despite recommendations, the patient still continued to take 1000 mg of Keppra twice a day and often times was not compliant with the medication. The patient was admitted to the hospital with generalized tonic-clonic seizures without loss of consciousness, urinary or fecal incontinence, or tongue biting. It was also mentioned the patient had no neurologic deficits at the time of admission. The patient received treatment with Keppra and was seen by a neurologist. According to the neurologist, the patient had a focal seizure related to cerebral astrocytoma and noncompliance with medications. The neurologist recommended taking Keppra 1250 mg twice a day, as well as social services intervention to improve compliance with seizure medications. Neurosurgery service did not recommend any further intervention. The health plan's determination of medical necessity is upheld in whole. The patient, who was previously diagnosed with a seizure disorder, presented to the hospital with a focal seizure. It was clear that the breakthrough seizure occurred because the patient was noncompliant with the regimen of anti-seizure medications previously recommended. While in the hospital, the patient remained afebrile and hemodynamically stable. The patient also remained seizure-free after the previously recommended dose of Keppra was reinstated. Laboratory evaluation demonstrated no clinically significant abnormalities that would justify admission at the acute inpatient level of care. There was no evidence of the patient having a concomitant condition that would justify admission at the acute inpatient level of care. Neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  ACL tear and meniscal injury
Treatment:  Continued physical therapy

The physical therapy visits were not medically necessary based on the available clinical information.  

A review of the medical notes shows that the patient did not have any post-operative complications such as infection, delayed wound healing, or arthrofibrosis.  The clinical note at the beginning date of service states "she has not had knee discomfort lately".  The notes show that as of that date she was able to walk with full weight bearing on the right lower limb without an assistive device.  Her right knee flexion was within functional limits and her right knee extension was full.  She had 4-/5 right hip and knee strength.  The notes state that the patient reported quadriceps fatigue after leg presses but no knee pain or discomfort.  As of the dates of service under review, the patient had a level of function whereby she could have been discharged on a home exercise program for continued hip and knee muscle strengthening.  Reference #1 below indicates that the usual frequency and duration of skilled physical therapy following anterior cruciate ligament repair is up to 40 visits within 26 weeks in uncomplicated cases.  The patient had an adequate number of skilled physical therapy visits as of the dates under review to be safely and effectively discharged to a home treatment program.

The clinical notes from visits after the first date of service under review did not clearly show that the skilled physical therapy the patient received was any better in quality than what she could have had with a consistent home exercise program.
Appeal type: Medical necessity
Decision: Upheld

Breathing Problem
Inpatient Hospital

The patient is a woman with a history of diabetes, hypertension, chronic obstructive pulmonary disease (COPD) and carotid arterial disease. She underwent video-assisted thoracoscopy for planned right middle lobe lobectomy for a lung mass. However, pleural lesions and a pleural effusion were found. Biopsies were taken but the lobectomy was not performed. The biopsy results were nondiagnostic. A month later she presented to the emergency department complaining of several days of dyspnea, cough and chest pain that was exacerbated by coughing and movement. Her blood pressure was 129/65 mmHg with a heart rate of 106 beats/minute. Her respiratory rate was 20/minute. Room air oxygen saturation was 100%. She was afebrile. On physical exam, there were decreased breath sounds over the right lung field. Chest X-ray showed a small right pleural effusion, pleural thickening and fluid in the right major fissure. Her troponin level was normal; her BNP level was mildly elevated. She was treated with bronchodilators, antibiotics and Lasix. The admission note indicates she was admitted for percutaneous drainage of the pleural effusion by an interventional radiologist. 

The health plan's determination is upheld. Based on the records provided, an inpatient level of care was not medically necessary.
This patient, with a known pleural effusion and lung mass, presented with pleuritic chest pain, dyspnea and cough. She was hemodynamically stable and her room air oxygen saturation was 100%. The documented reason for admission was for drainage of the effusion; however, this was not performed during the hospitalization and was scheduled for a later date. A lower level of care was reasonable in an attempt to alleviate the patient's symptoms, her effusion was small, she was not hypoxic and was not in marked distress. She did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Right upper quadrant pain 
Treatment:  Inpatient Stay
The Inpatient admission was not medically necessary.

The patient is a male with history of gallstones for eight to ten years.  He has occasional right upper quadrant pain without any flank pain or pain when he eats, with no nausea vomiting, diarrhea or chest pain. 

The patient was admitted for elective robotic assisted laparoscopic cholecystectomy. He tolerated the surgery well and was admitted for overnight monitoring and pain control. 

After an uncomplicated elective laparoscopic cholecystectomy, patients can drink clear liquids once awake from anesthesia, and their diet can be advanced as tolerated.

Most otherwise healthy, reliable patients with good home support can leave the hospital within six hours after surgery.  Cochrane reviews have found no significant differences for important clinical outcomes for patients discharged the same day versus admitted overnight following laparoscopic cholecystectomy.  A retrospective review of the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) database, which included 15,248 patients older than 65 years of age who underwent elective laparoscopic cholecystectomy, identified congestive heart failure, American Society of Anesthesiologists class 4, bleeding disorder, and renal failure requiring dialysis as significant independent predictors of inpatient admission and mortality.

This was a routine elective operation without any untoward events.  The patient could have been managed a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with psoriasis, 11% body surface area (BSA), treated with topicals. The provider is requesting Otezla. At issue is the medical necessity of Otezla.
The health plan's determination is upheld. According to the health plan final adverse determination (FAD) the member must have at least 10% BSA (met) and have tried and failed systemic therapy or phototherapy (not met). Clinical documentation was not included. While Otezla is likely an appropriate therapy for this patient, there are no documented contraindications to methotrexate. A 3-month trial of this medication would be within standard of care. Methotrexate is still commonly used for psoriasis. The formulary alternative (methotrexate) would not be inappropriate in this case. It appears phototherapy is not available in this patient's area. The Otezla is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Joint Problem/Pain
Inpatient Hospital

This is the case of a boy who presented to the emergency department (ED) with a 2 day history of pain and 1 day history of redness and swelling of the right foot and ankle. He had previously been seen by his primary care physician (PCP) and started on oral Keflex; he presented to the ED with worsening symptoms. There were no fevers and no history of trauma or recent travel.

The health plan's determination is overturned. Th inpatient stay was medically necessary. This patient presented with worsening cellulitis despite oral outpatient antibiotics, with pain and swelling that made him unable to ambulate. There was significant enough concern for osteomyelitis or septic joint that orthopedics was consulted in the ED and x-ray imaging was obtained. Per orthopedic recommendations and the expert guidelines references below, an inpatient hospitalization would be recommended for this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic fibroids-status post open abdominal myomectomy

Treatment: inpatient admission

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

This patient is a female with a history of symptomatic fibroids.  She underwent an abdominal myomectomy in early 2019. On postoperative day one, the patient was stable.  Patient controlled anesthesia (PCA) pump was discontinued, Foley catheter was discontinued and she was discharged home later that day. This patient underwent an open abdominal myomectomy.  In other words, she underwent a laparotomy.

Laparoscopies are ambulatory procedures, laparotomies are not. The standard of care for patients who undergo an open procedure is to stay in hospital for 48 hours.  Ideally this patient would have been admitted after surgery, on post-operative day one her Foley catheter and her PCA pump would have been discontinued.  She would be placed on clear liquids.  The patient will be reevaluated on post-operative day two, if stable and passing flatus, she will be discharged home.  This patient was discharged 24 hours earlier than expected.

According to Milliman Care Guidelines (MCG), Inpatient and Surgical Care, open abdominal myomectomies are not ambulatory procedures admission is medically necessary.

This patient had an open abdominal procedure, as such, admission was medically necessary and is standard of care. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

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

Diagnosis: Substance use disorder
Issue under review: Inpatient detox admission

Determination:
The Inpatient detox admission was not medically necessary.

The patient is an adult male. He presented for inpatient detoxification treatment in order to address substance use disorder with opioid (heroin), sedative-hypnotic-anxiolytic (benzodiazepine), stimulant (cocaine) and alcohol class substances of abuse. 

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. The treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder and co-occurring psychiatric disorder with associated symptoms of anxiety and insomnia. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or other emotional disturbances 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 received detoxification treatment and rehabilitation substance use treatment recently, as noted in the clinical summary. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with a past history of multiple treatment episodes. Thus, an inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.

This answer is consistent with New York State LOCADTR 3.0 Criteria and with established practice guidelines, the scientific literature, and ASAM Criteria, as referenced below.

In this case scenario, the patient was amenable to treatment with lower level care in a less restrictive setting. The patient displayed no serious disturbance of mental status. 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, as noted in the answer to question 2. There were no severe symptoms of withdrawal or biomedical issues in this case that would have required inpatient monitoring or services. The Inpatient admission for detoxification and withdrawal management and other medical services were therefore not medically necessary in this case scenario, as the health plan asserts. 

NY State LOCADTR 3.0 Criteria/Guidelines are not met for the inpatient level substance use disorder treatment, as referenced below.
Appeal type: Experimental/Investigational
Decision: Overturned

Digestive System/Gastrointestinal - Other
Surgical Services
The patient is a female with type 1 achalasia. She has had dysphagia for several years. She has cough if she lies down after eating. She has had respiratory symptoms including dyspnea and pleuritic chest pain, and pneumonia due to aspiration. Computed tomography scan of the chest showed markedly dilated thoracic esophagus with probable thickening of the gastroesophageal junction, as well as possible alveolar opacification/pneumonia related to aspiration. Esophagogastroduodenoscopy showed a dilated sigmoid esophagus with food and debris, consistent with achalasia. Esophageal manometry  showed type 1 achalasia with panesophageal pressurization in 90% of swallows, 100% failed swallows, and elevated basal and residual upper and lower esophageal sphincter pressures. Chest x-ray showed a dilated esophagus and bilateral nodular infiltrate. Esophagogram showed achalasia. The coverage is requested for peroral endoscopic myotomy (POEM) for the treatment of type I achalasia.

The health plan's determination is overturned.

The American Gastroenterological Association best-practice guideline for peroral endoscopic myotomy (POEM) states that "if the expertise is available, POEM should be considered as treatment option comparable with laparoscopic Heller myotomy for any of the achalasia syndromes" (Kahrilas, et al). The provider is a POEM expert (Stavropoulos, et al.). The American Society for Gastrointestinal Endoscopy has recently published a statement based on available evidence, stating that POEM is a "a potential attractive option for the treatment of achalasia that offers a minimally invasive endoscopic approach to myotomy with the potential for a durable response to therapy" (ASGE PIVI Committee, et al.). Clinical studies and trials have shown comparable efficacy with surgery when expertise in POEM is available (Barbieri, et al; Schlottmann, et al.). However, POEM is significantly less invasive than surgical intervention, resulting in less postoperative pain and a more rapid recovery (Docimo S, et al.). In this patient with severe symptoms, the use of POEM is supported by current medical literature and guidelines. For these reasons, POEM should be considered likely to be more beneficial than any standard treatment or treatments for the patient's type 1 achalasia.
Appeal type: Experimental/Investigational
Decision: Overturned

Digestive System/Gastrointestinal - Other
Surgical Services

Report # 1
The patient is a female with a confirmed diagnosis of achalasia-Type 1. The patient has had recurrent pneumonia due to achalasia with aspiration. The patient was initially referred for surgical myotomy but decided an endoscopic approach would be preferred. The patient endorses dysphagia, frequent heartburn and coughing while lying supine. Achalasia was confirmed with manometry, barium esophagram and endoscopy. She has end-stage achalasia with a sigmoid appearing esophagus.
The patient's provider has recommended a peroral endoscopic myotomy (POEM) procedure. This request was denied by the plan which considers it to be investigational.

The health plan's determination is overturned.

Yes. Treatment of achalasia is aimed at decreasing the resting pressure in the lower esophageal sphincter (LES) to a level at which the sphincter no longer impedes the passage of ingested material. This can be accomplished by mechanical disruption of the muscle fibers of the LES (e.g., pneumatic dilation, surgical myotomy or peroral endoscopic myotomy) or by pharmacological reduction in LES pressure (e.g., injection of botulinum toxin or use of oral nitrates). Very good results for POEM have been reported in patients with achalasia conditions that do not respond well to conventional therapies such as type III (spastic) achalasia and "end stage" achalasia (markedly dilated, sigmoid esophagus which is what this patient has), and in patients who have failed prior endoscopic and surgical achalasia treatments. (1-3)
Appeal type: Medical necessity
Decision: Overturned

Headache
Inpatient Hospital

The patient is a male with prior on compliance to anti-hypertensive therapy who presented to the emergency department (ED) (by Emergency Medical Services (EMS)) with complaints of feeling disoriented, headache and feeling unsteady. His initial blood pressure (BP) was noted to be 151/99. Of note, he was seen in the ED one day prior with similar complaints and BP elevation was noted to more than 200 systolic. He received treatment with amlodipine and HCTZ and left against medial advice. His exam was unremarkable. Vital signs were normal except his BP fluctuated with systolics ranging from 150s-low 200s. His initial lab work revealed mildly elevated creatinine at 1.49, troponin I at 0.066, Pro-BNp at 957. Head computed tomography (CT) in the ED was negative for stroke and showed encephalomalaia. With his neurologic symptoms and elevated BP, a diagnosis of hypertensive crisis and encephalopathy/ possible stroke was made. He was admitted to inpatient care.

The health plan's determination is overturned. The inpatient stay was medically necessary. Although the patient did not have any classic defining features of focal neurologic deficit indicating a clear stroke or hypertensive emergency including papilledema or severe end organ dysfunction like hypertensive encephalopathy, his symptom complex with disorientation, headache, and feeling unsteady did raise concern for posterior circulation involvement with transient ischemic attack (TIA) /Stroke. The MRI and neurology consult were appropriate for further evaluation. Based on risk evaluation for TIA (ABCD2 score), he was at a moderate high risk of future stroke. An inpatient level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Gastrointestinal Bleeding/ Bleeding of Intestines
Inpatient hospital

The patient is a female with medical history of hypertension, atrial fibrillation, hyperlipidemia, hypothyroidism, and multiple cerebrovascular accidents. She was on aspirin and Eliquis. She presented to the emergency department with vague diffuse abdominal pain and two episodes of bright red blood per rectum starting after a colonoscopy earlier that day. Vital signs were notable for hypertension with blood pressure of 161/107 mm Hg. Labs were notable for positive fecal blood; initial hemoglobin was normal. Computed tomography scan of the abdomen and pelvis with angiography showed active contrast extravasation in the cecum, colonic diverticulosis, and no free air. Gastroenterology consultation noted 3 episodes of bleeding per rectum after a colonoscopy the day prior. 

The health plan's determination is upheld. The inpatient stay is not medically necessary. In this case, the patient presented with lower gastroenterology bleeding, likely post-polypectomy bleeding. Computed tomography scan performed just after presentation ruled out other reasons for inpatient status, such as severe intra-abdominal process, obstruction, perforation, ischemic colitis, or toxic megacolon. The patient had monitoring of clinical status, vital signs, and daily labs, which were warranted. Gastroenterology consultation was performed soon after presentation. Colonoscopy identified the bleeding source, and appropriate intervention was performed. Eliquis, the anticoagulant the patient was taking, is not clearly associated with gastrointestinal bleeding, and has a half-life of approximately 12 hours. As hemodynamic status remained stable, there was no hypotension or hemodynamic decompensation, all of the measures that were undertaken could have been performed at a lower level of care without inpatient admission.