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

Diagnosis: Deviated nasal septum; chronic sinusitis

Treatment: Vestibular Stenosis repair procedure (code 30465)

 The insurer denied coverage for Vestibular Stenosis repair procedure (code 30465). The denial was reversed.

This patient is a female diagnosed with chronic sinusitis, and a deviated nasal septum.  The patient was treated with antibiotics, and nasal sprays. The CT scan of the sinuses revealed the nasal septum was deviated to the right.  There was a spur present.  There was a mild to moderate mucosal thickening in the bilateral maxillary sinuses.  The ostiomeatal complex was obstructed on the right side and the left side demonstrated infundibular stenosis.  

The physical examination indicated the patient had a nasal vault that was narrow.  The right nasal bone was depressed.  There was alar narrowing and mild vault weakness.  The septum was deviated.  There was bleeding on the right.  The operative indications included nasal congestion.  The endoscopy examination revealed the inferior turbinate was 2+ bilaterally.  The mucosa bilaterally had erythema.  The provider noted the patient's bone was depressed on the right due to a fracture in the past.  The patient was to be scheduled for an open reduction with treating the septum, a septoplasty, a turbinate reduction, and vestibular stenosis repair.

According to the referenced current medical literature, rhinoplasty and septoplasty may be performed to correct impaired breathing caused by structural defects in the nose, including to correct a deviated septum. The referenced peer-reviewed literature also notes that open structure rhinoplasty using spreader grafts, including autologous grafts, is effective in reconstruction of the internal nasal valve and preserving or improving nasal patency.

The patient had a history of a nasal fracture. On examination the patient had a depressed bone on the right and a narrow nasal vault with Alar narrowing and mid-vault weakness. These findings would support the requested vestibular stenosis repair. Therefore, the healthcare plan did not act reasonably and with sound medical judgment, and the best interest of the patient.  The vestibular stenosis repair procedure is considered medically necessary for this patient.

Based on the above, the medical necessity for the Vestibular Stenosis repair procedure (code 30465) is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bipolar disorder
Issue under review: Continued inpatient admission

Determination:
The Continued inpatient admission was not medically necessary.

The patient is a homeless male with history of bipolar disorder. He presented with a history of worsening depression.

By the dates of service under review, which was late in the month, the patient had consistently denied suicidal ideation for several weeks. Based on his mental status examination, this patient would have been a candidate for outpatient ECT by early in the month. The patient however was appropriately retained in the hospital due to psychosocial reasons, specifically the fact that he lived in a shelter, did not speak English fluently, and had no social supports. 

During the period in question, plans were made for the patient to live with his brother. His mood was bright. There was no evidence of psychosis, out-of-control behavior, or danger to self or others. Clinical indications for the additional two ECT treatments are unclear. In any case, nothing in the documentation reviewed indicates that the patient continued to require an acute inpatient level of care beyond the last covered day.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic anemia

Treatment: Inpatient hospital admission

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

This patient is a male with a past medical history of morbid obesity, hypertension, hyperlipidemia, atrial fibrillation, diabetes mellitus, and asthma.  The patient was sent to the Emergency Department by his primary care physician for low hemoglobin of 5.3.  The patient stated that he had been feeling tired for the last few months.  The patient had noticed a decrease in appetite.  The patient had no significant loss of weight.  There was no history of dark-colored stools or blood in the stools.  The patient complained of shortness of breath on exertion for the last few months.  The patient underwent a rectal examination, which revealed guaiac-negative stool.  The patient had never undergone a colonoscopy.  The laboratory studies revealed a white blood cell (WBC) count of 10.6, a hemoglobin of 5.5, a hematocrit of 17.7, a mean corpuscle volume (MCV) of 76.4, a blood urea nitrogen (BUN) of 16, a creatinine of 2.0 and an iron level of 29. The patient was admitted with a diagnosis of symptomatic anemia.  During the hospitalization, the patient was given a total of three units of blood and received daily intravenous ferric gluconate.  The patient underwent an esophagogastroduodenoscopy (EGD) revealing gastritis and a duodenal ulcer. The patient was discharged home and was to follow-up as an outpatient. 

The requested services were previously denied. The denial was based on MCG 23rd edition: Anemia, Iron Deficiency, or Unspecified ORG: M-35 (ISC) inpatient admission.
The healthcare plan did not act reasonably or with sound medical judgment or in the best interest of the patient. The inpatient hospital admission is considered medically necessary for this patient.

The patient had several severe comorbid factors including hypertension, hyperlipidemia, atrial fibrillation, morbid obesity, diabetes, and renal insufficiency.  He presented with severe symptomatic anemia of unclear etiology.  The most common cause of this presentation is gastrointestinal bleeding.  This was confirmed on endoscopy in this patient.  Although he was not found to be actively bleeding at presentation, this clinical profile of the patient is associated with increased issues in gastrointestinal (GI) bleed.  It was essential to correct severe anemia in a controlled manner, perform a GI work up and if this was negative, do a hematologic work up.  These tests could not have been done as an outpatient.  With so many serious possibilities and comorbidities requiring immediate addressing, observation status is inappropriate.  Inpatient admission was medically necessary.
 
The carrier's denial of coverage for the inpatient hospital admission is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for dementia and unsteady gait. Other secondary diagnoses include asthma and increased liver enzymes. Consumer directed personal-care assistant services 7 days a week 6 hours a day for a total 42 hours a week is being requested. 

The health plan's determination is upheld. The approved number of hours for personal care are sufficient to meet the patient's needs. Additional service hours are not medically necessary.  The records including the following reports were reviewed: Uniform Assessment System (UAS), Paraprofessional plan of care, Tasking tool Physician progress note.  The patient was previously approved for 6 hour a day 7 days a week and then the plan decreased the hours to 4 hours a day 7 days a week for a total 28 hours a week.

A review of the provided information noted the following: the patient was able to transfer, toilet and ambulate with set up help only. He was able to ambulate with the use of an assistive device. He was able to feed himself with meals that were prepared for him in advance. There have not been any noted falls, hospitalizations or emergency room visits in the last 90 days. His plan noted that it did not include provisions for safety monitoring as a separate task on related to performance of activities of daily living (ADLs) or instrumental activities of daily living (IADLs).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough, weakness and fatigue
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

While this patient did have stents placed three months prior, there was no evidence of any active ischemia, nor symptoms related to cardiac causes, nor any objective tests that support that ischemia was present. His symptoms were fatigue and weakness, likely due to an illness of the prior three weeks. The physicians' orders did not require treatment but only orders for non-invasive tests that were all normal. 

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. In this case, the patient's symptoms were atypical and unlikely to be representative of acute coronary syndrome (ACS). His exam and cardiac findings were normal. Biomarkers and EKG (electrocardiogram) showed no evidence of acute ischemia. CXR (chest x-ray) was normal. Echocardiogram showed no wall motion abnormality (WMA).  Nuclear scan was negative for CAD. The physicians' treatment did not reflect any serious concern about the patient's active cardiac condition.  Orders did not include medical therapy for ACS, such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV NTG (nitroglycerin). 
  
The letter of appeal was carefully considered, but it offered no evidence to support an inpatient level of care. The only cardiac care provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required an inpatient level. This patient had no evidence of active CAD. In fact, all tests showed absence of ongoing ischemia.  While there was always a potential for an adverse event (and in this case a very low probability), one did not happen, and no actual treatment was added.

Milliman criteria requirements were not fulfilled, as there was never any evidence of ACS present. There is no evidence that patient could not have been treated safely in a lower level of care. All of the testing and therapy that were provided would have been appropriate, safe and guidelines-consistent in a lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

The patient described dyspnea on exertion to his cardiologist. A nuclear stress test was performed and showed evidence of reversible antero-apical ischemia. The patient had prior history of coronary artery disease with previous intervention, hypertension, hyperlipidemia, and diabetes. The patient underwent diagnostic cardiac catheterization and was found to have severe circumflex stenosis of 95% in-stent restenosis proximally and 80% in mid vessel. There was also a 70% right coronary artery (RCA) lesion. The patient underwent successful drug-eluting stenting and was admitted. The patient was observed uneventfully and discharged the following day. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient had an elective diagnostic catheterization and coronary intervention for stable angina. The patient tolerated the procedure well. There were no intraoperative or postoperative complications. The patient remained stable throughout the procedure and the postoperative period. It was reasonable and appropriate to monitor the patient for several hours after the procedure. However, it was very likely that the patient would be ready for discharge with 8-23 hours after the procedure. Thus, the patient could have been observed at a lower level of care. An inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Alcohol Abuse/Addiction
Inpatient Hospital

This is the case of a male with past medical history of alcohol dependence and reports of prior ethyl alcohol (ETOH) withdrawal seizure, who presented to the emergency department with chief complaint of being found publicly intoxicated. The patient reported his last drink was the day prior. He denied chest pain, headaches, shortness of breath, abdominal pain, or other complaints.
On presentation to the emergency room (ER), he was afebrile with blood pressure (BP) 136/88, heart rate (HR) 107, respiratory rate (RR) 20, with oxygen saturation of 98% on room air (RA). Exam was otherwise notable for the patient appearing comfortable and in no distress. labs noted complete blood count (CBC) within normal limits, and aspartate aminotransferase (AST) 221, alanine aminotransferase (ALT) 130 with the rest of his comprehensive metabolic panel (CMP) within normal limits. Electrocardiogram (EKG) showed normal sinus rhythm without acute ischemia. The patient was given a dose of Librium and intravenous fluids (IVF). His Clinical Institute Withdrawal Assessment (CIWA) was subsequently noted to be greater than (>)10, and he was given Valium after which the decision was made to bring him into the hospital.

The health plan's determination is upheld.

This is a patient who presented after being found publicly intoxicated. As noted in the summary above, he was hemodynamically stable on presentation to the emergency department, without persistent hypertension or tachycardia, was alert and oriented, and his primary symptom of withdrawal appeared to be tremors with some diaphoresis. He was brought into the hospital with primary diagnosis of alcohol withdrawal. For the remainder of his hospitalization, as noted above, he remained hemodynamically stable. The records suggest that he stayed in the hospital primarily for tapering of Ativan as well as in the setting of diffuse itchiness, and because he appealed his discharge. It is unclear why tapering of his Ativan in the setting of hemodynamic stability and with his only other complaint being diffuse itching which did not require inpatient treatment, why his treatment required acute inpatient care and why he could not have been treated at a lower level of care status. Hospitalization at the acute inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment:Continued residential rehabilitation treatment 

The requested benefit of continued residential rehabilitation treatment is not medically necessary for this patient.

The patient presented with substance use disorders with the past use of heroin and medication assisted treatment with Suboxone, with continued use of large quantities of alcohol on a daily continuous basis with decline in functioning and psychosocial consequences/stressors. He received stabilization treatment transitioning to residential level rehabilitation treatment. He readily engaged in treatment with continued use of Suboxone and medications to address mood, trauma-related and attentional disorders including medication to assist with smoking cessation. 

During the time interval under review, the patient was noted to be in no apparent distress with improved functioning and active participation in treatment including positive interactions with staff and peers. From the time period under review and forward, there were no remaining treatment issues or biomedical or co-occurring psychiatric issues that would have warranted continued residential level of care. The application of NY State OASAS LOCADTR Criteria (referenced below) did indicate that the patient was clinically appropriate for treatment with lower level care in a less restrictive treatment setting, as the health plan asserts. Thus, medical necessity for the continued residential rehabilitation treatment is not met in this case scenario consistent with ASAM Criteria, the scientific literature and published guidelines, referenced below.

The patient in this case scenario is not clinically appropriate for the continued residential level of care during the time interval under review. The patient had reached a level of stability by the time period under review that he no longer warranted residential level care and could have been effectively managed in a less restrictive treatment setting with sober supports and monitoring. He no longer needed 24-hour monitoring or the intensity of residential level treatment to address the co-occurring psychiatric disorders of remaining symptoms related to his substance use disorders. He was engaged with treatment and involved with peer supported recovery groups while continuing medication assisted treatment with Suboxone and his psychotropic medications, as noted in the clinical summary. Thus, the health plan's determination is reasonable in this case scenario. This answer is consistent with prevailing standards of medical practice for the conditions diagnosed and under treatment in this case, and entirely consistent with the NY State instruction and OASAS LOCADTR Guidelines applicable in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and vomiting
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

The patient's condition did not require acute inpatient care.  She did have a history of brain abscess and subdural empyema and was being treated for this with a PICC line and at-home IV antibiotics.  Upon presentation, she had no neurologic changes or vital sign issues.  She did have some nausea/vomiting and abdominal pain.  Her CT scan showed no acute worsening from her prior imaging.  Neurosurgery recommended an MRI with contrast; however, this test did not require inpatient admission to obtain. There were no other medical issues necessitating acute inpatient care.   All consults and diagnostic tests could have been obtained at a lower level of care.  She was tolerating a regular diet by the day of discharge.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who was admitted for acute inpatient psychiatric services due to an overdose of his pain medications together with alcohol in the context of worsening symptoms of depression. He was in treatment for depressive disorder in the context of substance abuse with alcohol and general medical problems that included chronic pain associated with multiple surgical procedures and past injuries. He has a history of multiple psychiatric hospitalizations and emergency department visits for depression and general medical concerns and had recently been discharged from hospital level treatment. The patient was stabilized in the emergency department and medically cleared prior to his admission for acute inpatient psychiatric services. He had persistent complaints of pain in the context of overuse of his oxycodone. His alcohol use had escalated that contributed to his depression and hopelessness.
The patient has a history of alcohol use disorder with prescribed opioids, as noted. There was no other use of substances of abuse though he was tobacco dependent.
The health plan's determination is upheld. The patient was medically stabilized prior to his admission for psychiatric care. He did not present with acute general medical complications, or severe withdrawal symptoms or complications of co-occurring alcohol use disorder. Following admission, the patient had been treated for the mood disturbance and associated symptoms of anxiety/insomnia and functional impairments with improvement in symptoms and functioning; he did not require continued acute inpatient level structure or monitoring during the time interval under review. There was no further risk for suicidal behavior or documented symptoms that would have warranted continued assessment, safety monitoring and treatment in an acute inpatient setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left ankle injury
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

This young man was found to have an unstable ankle fracture. He underwent stress views demonstrating associated injury to the medial ligament. He required operative intervention to stabilize his lateral ankle. His physician placed a surgical incision, identified and stabilized the fracture with screws and plate. The procedure would be associated with complexity. This young man would be expected to have pain and require IV or other narcotic analgesia. These services would require the inpatient hospitalization. These services would not applicable at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diverticulosis

Treatment: Inpatient hospital admission

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

This patient is a female who presented with rectal bleeding.  She was afebrile and the vital signs were stable.  The abdominal exam was negative but the rectal exam revealed melena.  The hemoglobin fell from 10.2 to 9.3 without receiving intravenous fluids.  The progress notes state that the patient was having ongoing bleeding.  There were four episodes of bloody stool in the Emergency Room (ER) and then 3-4 more episodes of rectal bleeding prior to the colonoscopy.  The colonoscopy revealed diverticulosis with clots and old blood.  Afterwards, the bleeding stopped.

Clinical indications for admission for lower gastrointestinal bleeding (M-182) include having ongoing active bleeding as manifested by recurrent hematochezia.  The patient met this indication.  There were multiple continued episodes of bleeding both in the Emergency Room and the following day.  The initial rectal exam revealed melena and the colonoscopy showed multiple blood clots.

The healthcare plan did not act reasonably and in the best interest of the patient.  Inpatient medical services were medically necessary.  The denial is reversed.

The carrier's denial of coverage for the inpatient hospital admission at the acute inpatient level of care is reversed.  The medical necessity is substantiated.