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

Diagnosis: Opioid dependence
Treatment: Inpatient admission
The continued inpatient admission was medically necessary for this patient.
The requested benefit of continued inpatient admission could not have been effectively provided at a lower level of care in this case scenario. The patient in this case was using large quantities of heroin and cocaine that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. Detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms that were being effectively addressed with methadone and supportive measures provided during the time interval under review. The patient had associated clinical features that included a depressive disorder treated with Lexapro, and he presented with a lack of sober supports and limited insight, impaired judgment and poor control of impulses. 
Thus, the adult inpatient stay and continued detoxification treatment of this patient's substance use disorders did warrant and require the continued structure of an inpatient level setting with withdrawal management and psychosocial supports, and 24-hour monitoring. The patient's history of substance abuse (frequency and quantity) together with the co-occurring depressive disorder and severe psychosocial stressors and functional impairments do reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure 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 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 therefore should be covered in this case scenario. The continued inpatient level treatment through discharge could not have been effectively provided with lower level services, as noted in the answer to question 2. Thus, the requested should be covered in keeping with prevailing standards of care pertaining to substance use disorder services, including consideration of ASAM Criteria and application of NY State OASAS LOCADTR 3.0 Criteria, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
 
Treatment: Inpatient admission, medication, monitoring

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

The patient presented with abdominal pain and nausea.  Her vital signs were stable.  There was no abdominal rebound or guarding.  A CAT scan showed a subcapsular hypodensity of the spleen which was felt to represent a small subcapsular hematoma.  The patient was treated with proton pump inhibitor (PPI) therapy and Zofran.  An endoscopy was advised but the patient absconded from the hospital.

Clinical indications for admission for undiagnosed abdominal pain (MCG M-05) include the need for surgery that cannot be performed on an outpatient basis and peritoneal signs.  The patient did not have these conditions.  She also did not have hemodynamic instability, intestinal obstruction, or a severe electrolyte abnormality.

This patient had a history of gastroesophageal reflux disease (GERD) and a fundoplication.  She required an endoscopy.  However, she was stable to have had the endoscopy performed on an outpatient basis.  Intravenous hydration, PPI therapy, and anti-emetics could have been given in the Emergency Room (ER) with observation status.  The patient did not meet MCG criteria for admission for undiagnosed abdominal pain.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mood dysregulation
Treatment: Residential treatment admission
The residential treatment admission was not medically necessary.

This patient's ongoing acting out behaviors were consistent with severe parent-child relational problems as well as her initial diagnosis of borderline personality disorder. The usual and acceptable standard of care for such conditions involves ongoing outpatient treatment, with possible partial hospitalization in the patient's community, and brief acute admissions only for situations of imminent danger. 

The patient's chronic acting out behaviors as described in progress notes did not represent an acute danger to self or others, did not require 24-hour daily observation and treatment, and were unlikely to improve with such treatment.

It is apparent from the progress notes that this patient was unable to derive any benefit whatsoever from this residential stay. Furthermore, there was no evidence of appropriate psychiatric involvement throughout the stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain
 
Treatment:  Inpatient Admission 

The insurer denied the Inpatient Admission.  The denial was upheld.
This case involves a female patient who presented to the Emergency Room complaining of abdominal pain.  The patient had a past medical history of cholelithiasis, gastritis and hypertension.  The patient had ongoing epigastric pain radiating to the lower abdomen for two months, but it had been progressively getting worse.  The patient had been seen three times for abdominal pain.  The patient had normal blood work, CT scan and sonograms.  The patient had undergone a Gastroenterology physician referral.  At the last visit, the patient was admitted and underwent an endoscopy showing mild gastritis and was prescribed omeprazole.  The patient had been compliant.  The patient continued to have pain.  The patient had associated nausea and vomiting.
 The patient was admitted in a nothing by mouth status and underwent an ERCP with removal of a 5 mm stone and subsequently underwent a laparoscopic cholecystectomy. The records failed to support that the patient went to surgery immediately from the Emergency Room to support that this was an emergent procedure.  The patient was not noted to have complications from her comorbidity, hypertension.  The patient could have been placed on observation status and discharged from the Postanesthesia Care Unit once stabilized.
The inpatient admission is not considered medically necessary for this 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: Myasthenia gravis
Issue under review: IVIG

Determination:
The IVIG is not medically necessary.

The patient's neurological examination without intravenous immunoglobulin, was completely normal. Therefore, the patient is clinically stable and her symptoms are controlled with Mestinon. There is no documentation of ptosis, diplopia, abnormal swallowing or abnormal gait. FDA as well as peer-reviewed published medical literature do not support the use of intravenous immunoglobulin for maintenance of myasthenia. Additionally, there is no evidence in the published medical literature that intravenous immunoglobulin in myasthenia has any advantages comparing to cyclosporine or tacrolimus for disease maintenance. In the absence of such evidence, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hearing loss
Issue uder review: Hyperbaric oxygen treatment

Determination:
The Hyperbaric oxygen treatment is medically necessary.

The patient had significant hearing loss without improvement with steroids. Although HBO may not universally benefit patients, the patient failed first line therapy. Adjunctive HBO is appropriate and medically necessary as an attempt to restore some hearing as supported by the cited literature. Although the health plan followed Medicare Guidelines, it is in the patient's best interest to obtain HBO to attempt to restore hearing.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Concussion
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

This male infant hit his head two days in a row while crawling.  He had no loss of consciousness, but after the second episode became much sleepier than usual and began vomiting.  While in the ED, he developed fever to 103 and had multiple episodes of copious watery diarrhea.  Although he was cared for at home and has no siblings, he had spent a week in a daycare center the week prior.  Once he had been observed on the Trauma service overnight for sequelae from the head trauma, he was transferred to the Pediatric service because of signs and symptoms consistent with acute gastroenteritis.  His symptoms improved sufficiently overnight the second night that he was able to discharge home. 

It was reasonable and appropriate to monitor the baby for a period of time after the consecutive minor closed head injuries because he was symptomatic with vomiting and lethargy.  However, based on the subsequent development of fever and vomiting, it was clear that his head injury was not the only issue.  He had developed signs and symptoms consistent with acute gastroenteritis.  Regardless, he remained hemodynamically stable throughout, was able to successfully transition to his oral diet, and had no evidence of sepsis or intracranial hemorrhage.  He did not require acute inpatient management (for either the head trauma or the gastroenteritis) and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented with a subjective fever, diarrhea for three days, and vomiting for two days. Four days prior to admission he had a cough and nasal congestion which cleared up with Saline nose spray and suction. He had 4-5 episodes of diarrhea each day for the last three days prior to admission. His mother noticed some bright red streaking in his diapers with almost every diarrheal stool. She also noted some hard stool chunks mixed with loose stool. She also noted that he seemed to cry in pain with passage of stool. He also had 5 episodes of non-bilious non-bloody emesis over the past two days prior to admission. The health plan's determination is upheld. His clinical findings, described in the chart, along with his laboratory findings support a mild degree of dehydration. There was no mention of a PO trial in the emergency room after he received an IV fluid bolus as oral rehydration therapy is the recommended first line for mild to moderate dehydration. He did not meet currently accepted criteria for admission to the hospital for dehydration.
Appeal type: Medical necessity
Decision: Overturned

The patient has hidradenitis suppurativa (HS) that is active in the groin, buttock, inframammary folds with painful draining sinus tracts. The health care provider is requesting coverage for Humira.

The health plan's determination is overturned. Humira is medically necessary. Humira is the only Food and Drug Administration (FDA) approved medication indicated for moderate to severe HS and has the highest level of evidence compared to systemic antibiotics whose role is limited in advanced HS with higher recurrence rates and lower responses. The patient has moderate to severe HS based on the presence of draining sinus tracts and is an appropriate candidate for Humira.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hepatic encephalopathy
 
Treatment: Inpatient admission

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

This case involves a male with a past medical history of cirrhosis, diabetes mellitus, schizophrenia, chronic back pain, banding for esophageal varices, anemia, ascites, depression, recurrent hepatic encephalopathy and hypertension.  The patient was brought to the hospital for confusion, imbalance and dizziness.  Family at the bedside stated the patient had been increasingly more confused over the last few days.  The initial evaluation revealed the patient was alert and oriented to name and place, but not to time.  The patient did not know why he was at the hospital.  He denied pain or discomfort.  The patient's ammonia was in the 140s.  The physical examination was benign outside of confusion, asterixis (hand tremor) and abdominal distention with spidering angiomas.  Laboratory studies were to be drawn for infection and the patient was admitted for further management.  A CT scan of the head was negative for intracranial pathology, and an abdominal ultrasound was negative for ascites. The patient was stabilized and discharged on Lactulose twice per day.

The Milliman Care Guidelines indicates 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 for confusion 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 of severe neurologic finding. 

In the setting of recurrent hepatic encephalopathy, observation would be appropriate. There was no indication of lethargy, altered mental status that was severe or persistent, or difficulty following commands. Dizziness could be treated on an outpatient basis. The records failed to support the patient was not appropriate for observation as he improved with an initial dose of Lactulose, and was treated with Lactulose during his stay. 

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

The patient was admitted with the diagnosis of pneumonia. She was discharged home the following day. The patient had no significant past medical history and presented to her primary care physician (or provider) with a four day history of abdominal pain and a 10 day history of cough.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient required no IV fluids and was discharged the following day. There is nothing in the medical record that would cause this admission to meet inpatient status requirements. The patient could have been reasonably and safely treated at a lower level.
Appeal type: Medical necessity
Decision: Upheld

The patient has a medical history significant for left sided weakness who was admitted to subacute rehabilitation following an acute hospital stay for atypical chest pain and arrhythmia. 

The health plan's determination is upheld. The continued subacute rehabilitation is not medically necessary. Records reviewed noted the patient to have made significant gains in therapy and be at a level capable for discharge to a lower level of care. In addition, the patient was plateauing in therapy. A continued stay in subacute rehabilitation at this level is not within generally accepted clinical standards as the patient is medically stable and at a functional level appropriate for discharge.
Appeal type: Medical necessity
Decision: Overturned

The patient is an infant with vein of Galen malformation with ongoing, severe high-output heart failure, pulmonary hypertension, chronic respiratory failure and complex atrial arrhythmias. He was transferred for a diagnostic cardiac catheterization and ablation of foci, with a return to the originating hospital after the procedure. The health plan has denied the return inpatient stay at the originating hospital as not medically necessary. The health plan's determination is overturned. The arrangement for the transfer back to the originating hospital allowed the child's mother, his sole caregiver, to remain actively involved in his care. His situation is complex, atypical, and rare. The inpatient services were medically necessary, affording this critically ill infant his best chance at survival.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: schizoaffective disorder versus schizophrenia, anxiety/depressive disorder
 
Treatment: medication, therapy, and monitoring

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

Reviewer Findings:

The patient was admitted to inpatient mental health treatment due to agitation, anxiety, irritable mood, and restlessness, and somatic complaints.  She had past reported psychiatric hospitalization.  She reportedly lived alone and was unemployed.

The insurer denied coverage for continued inpatient mental health treatment as not medically necessary, and they recommended a less restrictive level of care.

The chart notes did not provide evidence to support that she could not be safely and effectively treated in at a less restrictive level of care.  

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior are candidates for inpatient treatment.  As of Day #10 there were no reports of psychotic symptoms such as delusions, hallucinations, or disorganized thinking or behavior, suicidal or homicidal ideation, intent, or plan, manic symptoms, aggressive, threatening, self-injurious, or agitated behavior, withdrawal symptoms or acute medical instability.  There were no acute or severe mental health or behavioral symptoms that required 24 hour acute hospital treatment. She had linear thoughts, fair judgment, was compliant, calm and cooperative with staff. She had goal directed thoughts with no risk behaviors reported.
Appeal type: Medical necessity
Decision: Overturned

At the time of service the patient underwent an (L)3-4 lumbar decompression for spinal stenosis.  The patient's past medical history (PMH) was significant for benign prostatic hyperplasia (BPH) with urinary frequency, being overweight, pre-diabetes mellitus and treatment for Hepatitis C.  The prior past surgical history (PSH) was significant for an L45 laminectomy in 2012.  The patient was initially admitted as a 24-hour observation, and his procedure was completed in the late afternoon, arriving in the post-anesthesia care unit (PACU) that day.  The patient was eventually transferred to the floor.  The subject under review is the medical necessity for the inpatient hospital stay.

The health plan's determination is overturned.  POUR (post-operative urinary retention) is a common occurrence following elective spinal surgery, particularly posterior lumbar surgery, and can lead to increased morbidity and increased hospital stay.  This complication is also more common in patients with BPH, chronic constipation or prior urinary retention and those patients using a patient-controlled analgesia (PCA) (not applicable in this case).  The patient did have a prior history, related to the PA after the POUR had been diagnosed, of urinary frequency preoperatively; however, the patient was not on medications for this, although he had seen a urologist in the past.  If left untreated or inadequately treated, POUR can lead to UTIs (urinary tract infections), bladder over-distention, sepsis and autonomic dysregulation.
The patient was diagnosed and treated with I/O catheterization and medication (Flomax), as well as mobilization which was documented both by PT and the nursing notes.
Due to complications that can arise from this indwelling Foley catheter, invasive device, such as urethral injury, urinary tract infections (UTIs) and/or sepsis, as well as then allowing the medication to take effect, this patient was able to be discharged with improving bladder function and without an indwelling FC.
In reviewing the Milliman Care Guidelines (MCG) guidelines for an uncomplicated lumbar laminectomy there is a mandate for voiding ability to be at baseline, with no new voiding issues, in order for a patient to be discharged on hospital day HD#2 (post-operative day POD #1).  This was not the case, as the patient had difficulty in his voiding attempts, which was different from his baseline.  Per the records, it is noted in addition, under the hospital care planning section there is a notation that hospital evaluation and care needs may include monitoring a patient's status for deterioration and comorbidities including urinary retention, and that monitoring also warrants appropriate treatment.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who presented for inpatient detoxification treatment  in order to address severe substance use disorder with opioid (heroin) class substance of abuse. The patient was also hepatitis C positive and on treatment with Epclusa. He reported a past history of severe withdrawal symptoms when attempting to curtail his use and had undergone a prior detoxification treatment with relapse and resumption of use of heroin. The health plan's determination is overturned.The continued inpatient treatment of this patient's substance use disorder with detoxification and withdrawal management did require the continued structure of an inpatient level setting and 24-hour monitoring in view of the patient's clinical presentation and course of treatment and risk factors for relapse and lack of a reasonable treatment/recovery environment. Withdrawal symptoms were appropriately managed with tapering dosages of methadone requiring monitoring and supportive measures including the availability of nicotine replacement therapy and comfort medications, as noted in the clinical summary. The patient's history of opioid use, limited psychosocial supports and psychosocial stressors within several domains including limited social supports and legal issues, and risk for relapse in view of his past history of detoxification with relapse did reflect the seriousness of the substance use disorder and a complicated case with regard to the ongoing struggle with addiction and general medical complications requiring ongoing treatment for hepatitis C.