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

Diagnosis: Alcohol Abuse/Addiction, Major Depressive Disorder
Treatment: Inpatient Hospital (Substance Abuse)

Summary: This patient was admitted to this inpatient medical hospital for alcohol detoxification treatment after he presented to the Emergency Department (ED). He had active alcohol withdrawal symptoms including diaphoresis, tremors, tactile hallucinations, recurrent nausea, vomiting, severe anxiety, and abdominal pain. He had alcohol gastritis and hypertension. He had been drinking large amounts of alcohol including three pints of vodka per day and reported drinking since the age of 19. He also had a history of cannabis use. He had reports of iron deficiency anemia, low sodium and potassium and acute dehydration. He also had a reported history of Major Depressive Disorder and was taking Mirtazapine. 

The insurer has denied coverage for inpatient hospital as not medically necessary. The denial was reversed. 

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. It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal. They also report that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he did require 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting. This was evidenced by the fact that he continued to use alcohol, needed detoxification medication to modify withdrawal from alcohol, and he was at risk for worsened withdrawal symptoms if not in this 24-hour setting. This includes possible life-threatening withdrawal such as delirium tremens. This patient could not safely be treated in an outpatient detoxification as he was drinking large amounts of alcohol daily- up to three pints per day and had alcohol withdrawal symptoms including diaphoresis, tremors, tactile hallucinations, recurrent nausea, vomiting, severe anxiety, and abdominal pain. Additionally, he had comorbid medical issues including alcohol gastritis, low sodium, low potassium, anemia, elevated liver function tests, and he required and received Ativan for detoxification treatment. He was at risk for severe, complicated and life-threatening withdrawal and required 24-hour hospital detoxification treatment.
Appeal type: Medical necessity
Decision: Overturned in Part

The patient with a past medical history significant for diabetes mellitus type 2, hypertension, alcohol dependence, and severe depression complicated by prior suicide attempt, was brought by medics to the Emergency Department for evaluation due to active suicidal ideation in the setting of acute alcohol intoxication.
Apparently, the patient had recently completed an inpatient rehabilitation program but relapsed on alcohol and had been drinking heavily and told friends and family that the patient wanted to self-harm. The patient had a history of multiple acute inpatient psychiatric hospitalizations for suicidal ideation and previously attempted to commit suicide by jumping out of a 16-story hospital window.

Laboratory studies demonstrated that the sodium was 135, potassium 3.3, chloride 95, bicarbonate 26, blood urea nitrogen (BUN) 19, creatinine 0.71, and glucose 157. Liver function tests were unremarkable. White blood cell count was 4.3, hemoglobin 11.9, hematocrit 36.9, platelets 18. An electrocardiogram demonstrated normal sinus rhythm with QTc prolongation measuring 492 milliseconds. The chest radiograph demonstrated no acute findings. In the emergency department, the patient was treated with intravenous fluids, intravenous lorazepam 2 milligrams (mg), and started on continuous 1:1 observation.
The patient was admitted to the hospital with alcohol intoxication with symptoms of alcohol withdrawal. The patient was also diagnosed with thrombocytopenia, which was attributed to myelosuppression due to the alcohol abuse. Another clinical problem was mild hypokalemia, and therefore the patient received potassium supplements.
At the time of admission, Clinical Institute Withdrawal Assessment (CIWA) score was 0. Subsequently, it was documented that the CIWA score went up to 11. During the hospital stay the patient was treated for alcohol intoxication and subsequently for alcohol withdrawal. The paitent received treatment with tapering doses of Ativan.

In the hospital, the patient was seen by a psychiatrist. When seen by a psychiatrist, the patient denied any suicidal or homicidal ideation. However, after the assessment, the psychiatrist recommended continuation of one-on-one observation. The patient was also seen by a hematologist/oncologist because of the thrombocytopenia. Apparently, the patient did not have any signs of bleeding, therefore no transfusion of platelets was recommended. The patient was seen by a cardiologist, who listed the patient's medical problems as diabetes, prolonged QT interval, and hypertension. In the plan section of the consultation note, there was no plan formulated. The patient underwent a stress test, which was negative. During the hospital stay the patient continued to be seen by a psychiatrist and was cleared for discharge.

The health plan's determination is overturned, in part. 

In this clinical case, the patient had a number of psychiatric conditions including alcoholism, depression, suicidal ideations,
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
 
Treatment: Inpatient substance detoxification

The insurer denied inpatient substance detoxification. That denial was reversed.

This patient was admitted to inpatient substance detoxification treatment from alcohol and opiates.  He had withdrawal symptoms including acute hand tremors, irritable and anxious mood, restlessness, malaise, abnormal pupil size, bone and joint aches, muscle cramps, gastrointestinal upset, and sleeping problems.  He reportedly was drinking 4-5 24 ounce beers per day and snorting up to 2 bundles of heroin per day and used cocaine.  He reportedly had blackouts due to use. He was incarcerated in the past.  He was unemployed.  He had over 10 past inpatient substance detoxification treatments and 4 past inpatient residential substance treatments. He reportedly had hepatitis C and hypertension.  He was on an Ativan protocol and Methadone taper regimen for detoxification.  He left against medical advice (AMA).

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  In this case this patient had use of multiple substances including heroin and alcohol as well as cocaine and was at risk for death from overdose.  

Inpatient substance detoxification was medically necessary. According to the Level of Care for Alcohol & Drug Treatment Referral (LOCADTR) he did require 24 hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use substances despite multiple past inpatient substance detoxification and residential rehabilitation treatments, and he had long term multiple substances of use.  He presented with withdrawal symptoms including acute hand tremors, irritable and anxious mood, restlessness, malaise, abnormal pupil size, bone and joint aches, muscle cramps, gastrointestinal upset, and sleeping problems. He was at risk of life threatening and complicated withdrawal such as delirium tremens which can occur 3-4 days after stopping alcohol or sedative use so he required 24 hour detoxification treatment.  He was using two detoxification medications including Ativan and Methadone to modify withdrawal and for detoxification. He continued to use alcohol and heroin despite past negative consequences including past incarceration and medical problems including hepatitis C.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System (COPD/Asthma)
Treatment: Inpatient Hospital

Summary: This patient with history of chronic obstructive pulmonary disease (COPD)/Asthma presented to the Emergency Department (ED) with complaints of shortness of breath with wheezing, chest tightness and worsening cold symptoms. She had been prescribed a Z pack but continued to have a persistent productive cough. The ED medical doctor documented vital signs at presentation were - heart rate (HR) 104, respiratory rate (RR) 22, and oxygen saturations were 93%. The patient was afebrile. Peak expiratory flow (PEF) was 150. The patient was in no acute distress. Lungs were clear. There was no use of accessory muscles or respiratory distress. Cardiac exam was normal. White blood count (WBC) was 8.6K, hemoglobin 12 g, and Arterial Blood Gas (ABG) was 7.35/50.9/41.8/27.  Electrolytes were within normal limits. Electrocardiogram (EKG) showed sinus tachycardia. Chest Computed Tomography (CT) scan revealed some mild centrilobular emphysema and some mild scarring/atelectasis of right upper lobe and right middle lobe. There was no evidence of active chest disease. The patient was treated with DuoNebs, Magnesium, intravenous (IV) steroids, Terbutaline, Mucomyst and IV fluids. The patient also received oxygen and was placed on Levofloxacin. 

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

As per the History & Physical (H&P) the patient was lying comfortably in bed, and was not in any apparent distress. Blood pressure (BP) was 120/86, RR 22, and oxygen saturations were 93% on room air. There was no use of accessory muscles. There was an occasional wheeze on the lung exam. The patient was awake alert and communicative. As per the H&P room air oxygen saturations were 93%.  PEF was 280 on admission (Baseline 300L/m). ABG was 7.37/45/64/24/93%. Chest x-ray showed no infiltrate. The patient was treated with a steroid taper, bronchodilators and Levofloxacin. The patient was afebrile and no leukocytosis is noted. The patient was seen by Pulmonary in consult who recommended a switch to oral prednisone for five days and oral Levofloxacin for four more days, then home medications and Chest Clinic follow-up after discharge. This patient did not need acute hospitalization. She could have been placed under observation status while diagnostic testing and treatment was initiated. The patient remained stable and was afebrile and hemodynamically stable. She was in no acute distress. Lungs showed minimal wheeze/clear. There was no pneumonia. WBC was normal. The patient was tolerating oral intake.  The patient was stable for discharge on oral meds and bronchodilator with close follow-up in an outpatient setting after a period of observation. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

This patient has a history of group B Streptococcus sepsis at three months.  She presented to the emergency department of the hospital for evaluation of vomiting and diarrhea x 2 since the day prior.  The mother reported going to the emergency department the night prior but was discharged home, and the patient's condition did not improve.  After presenting again to the emergency department, she was admitted for further management of acute gastroenteritis, dehydration and metabolic acidemia, including continued intravenous fluids and monitoring of electrolytes.  The insurer has denied coverage for the inpatient hospital services.  The denial was upheld.  This patient presented with mild tachycardia, dry mucus membranes and a mild acidosis.  Based on these findings, this patient likely presented with mild dehydration.  She presented to the emergency department the day prior and was discharged after a successful oral fluid challenge and administration of Zofran.  When she returned fluid resuscitation, laboratory evaluation, and admission were arranged in rapid succession without an opportunity to fully evaluate the outcome of each of the interventions.  A decision to admit the patient was made soon after her presentation.  Nursing reports from 12 AM, state that since admission the evening before the patient had neither vomiting nor diarrhea.  The following day she was kept in hospital despite nursing reports that she had neither vomiting nor diarrhea.  The patient did not fail an oral fluid challenge following fluid resuscitation and was not so profoundly dehydrated that she was beyond rehydration in the emergency department.  She was kept in the hospital despite remaining asymptomatic.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with history of asthma who presented to the emergency department (ED) with fever, body aches, and vomiting.  The patient had been treated as an outpatient prior to presentation.  The patient was treated in the hospital with fluids and antibiotics.  The health plan's determination is upheld.

The medical care could have been provided at a lower level of care based on the medical status of the patient and the services provided.
Appeal type: Medical necessity
Decision: Upheld

This patient has a history of hypertension, hyperlipidemia (treated with Repatha in the past), current tobacco use, depression and coronary artery bypass graft (CABG) x4 in 2008. She presented to another hospital earlier in 2018 due to progressive dyspnea with exertion and chest discomfort similar to prior to her CABG, was diagnosed with a non-ST-elevation myocardial infarction (peak troponin 0.51) and transferred for coronary angiography. Echocardiography revealed wall motion abnormalities and left ventricular ejection fraction 30%. At that time in 2018, she underwent percutaneous coronary intervention (PCI) and drug eluting stents (DES) in the left circumflex, obtuse marginal 2, and left main coronary arteries. She was followed in the cardiology clinic and referred for staged PCI to the right coronary artery.  Home medications included aspirin, clopidogrel, Atorvastatin, isosorbide mononitrate, metoprolol, spironolactone, Entresto, Citalopram, Ventolin metered dose inhaler and Vitamin D.  She underwent PCI and DES to the RCA via right radial artery subsequently in 2018.  Nursing and medical notes status post procedure indicate that there were no complications related to the procedure, with normal puncture site and no significant hemodynamic abnormalities.

The insurer denied coverage for the inpatient hospital services. The denial was upheld.

There is no evidence that this patient required an acute inpatient level of care for monitoring or management following elective percutaneous intervention.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dizziness
Treatment: Inpatient admission
Summary:  The inpatient admission was medically necessary.  The patient presented for evaluation of dizziness and was admitted for a concern of a malignant arrhythmia. The patient has significant history of heart disease and is s/p percutaneous aortic valve replacement. The patient had a history of underlying conduction disease, as evidenced by his abnormal ECG, and given risk of intermittent aortic valve (AV) block, a known complication of TAVR, as well as his prior history of SVT and non-sustained VT, further work-up and evaluation by cardiology and electrophysiology specialists were medically indicated. Given the presentation, complex medical history, as well as clinical suspicion for an acute cardiac arrhythmia, the patient would not be an appropriate candidate for an ED chest pain observation unit, and it would be consistent with the current standard of care that this patient be managed in an inpatient setting.  Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse and mental illness
Treatment: Inpatient admission
The inpatient admission was medically necessary.
The patient represented an acutely elevated risk of dangerous behaviors and there was no less-restrictive treatment environment appropriate.  The acute risk factors of depression, pain, and recent substance abuse with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of self-injurious behaviors (including but not limited to suicide) were he to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.
The patient represented an elevated risk of dangerous behaviors including self-injury and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore the treatment was medically necessary.  While the patient was not endorsing active suicidality or homicidality, the patient remained depressed and there were ongoing medication changes.  The patient had multiple static risk factors for potentially dangerous behaviors including prior suicide attempts, medical illness, chronic pain, and diagnosis with a severe mental illness.  Therefore the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained depressed and with ongoing medication changes were acute risk factors for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.
Appeal type: Medical necessity
Decision: Overturned

This patient with a history of alcoholism, anxiety, depression and asthma was admitted to inpatient detoxification treatment.  He had alcohol withdrawal symptoms including nausea, tremors, high blood pressure, elevated heart rate, and headache, as well as anxiety.  He was drinking 15-20 beers per day.  The patient reportedly had multiple past inpatient substance detoxification treatments including a recent one in 2018.  He had a history of past repetitive seizures due to alcohol withdrawal.  He also took Prozac, Trazodone, and Propranolol.
 
The insurer denied coverage for the inpatient detoxification treatment in the hospital. The denial was reversed.
 
The American Psychiatric Association Practice Guidelines for the Treatment of Patients with Substance Use Disorders report that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  It also states that patients with past complicated or life threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with co-morbid medical conditions that complicate the management of withdrawal are also candidates for inpatient detoxification.  This patient could not safely be treated in an outpatient detoxification.  He had past severe, life threatening, and complicated withdrawal symptoms, as he had past alcohol withdrawal seizures, so he was in need of this hospital detoxification treatment.  In this case this patient had been drinking large amounts daily, including drinking 15-20 beers daily.  According to the Level of Care for Alcohol  Drug Treatment Referral, the patient did require 24 hour treatment, as he could not safely and effectively be treated in outpatient detoxification settings because he continued to use alcohol daily despite reports that he failed previous inpatient treatments including a recent one.  The patient also required and needed detoxification medications to modify withdrawal and needed 24 hour treatment then, as he was at risk for worsened moderate withdrawal symptoms including life threatening Delirium Tremens if not in this 24 hour setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient substance abuse admission 
The proposed treatment, inpatient substance abuse 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. The acute inpatient 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 with alcohol and use of cocaine, and history of a mood disorder. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk for self-harm, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. 
There were no severe/objective symptoms of withdrawal or biomedical issues in this case, and the patient had knowledge of substance use disorder treatment protocols as he was participating in a methadone treatment program for opioid use disorder, as noted in the clinical summary. The patient had fair insight and control of impulses, and the working knowledge of substance use disorder treatment with a past history of multiple treatment episodes, as noted. Thus, admission for detoxification treatment with 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 OASAS LOCADTR 3.0 Criteria and with established practice guidelines, the scientific literature, and the American Society of Addiction Medicine (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 despite having a history of ongoing substance use disorder with alcohol and stimulants/cocaine. 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 above. The admission for detoxification treatment and 24-hour monitoring, and the 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 are not applicable in this case scenario for the inpatient level of care, referenced below.