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

Diagnosis: Urinary Tract Infection
Treatment: Continued inpatient admission. 
The insurer denied the continued inpatient admission.
The denial was upheld.

This is a female patient who presented to the Emergency Department (ED) after being evaluated by the Gynecologist's office for complaint of vaginal pain and hematuria.  The patient had 4+ blood in the urine in the office.  The patient had a pain score of 6/10.  Urinalysis showed presence of trace protein, moderate blood, small leukocytes, bacteria, squamous epithelial cells, calcium crystal.  The patient was admitted for urinary tract infection (UTI) and pain control.  The patient was seen by Infectious Diseases in consult.  The hospital course of treatment and management included intravenous Aztreonam, intravenous Rocephin, intravenous Morphine, continuous intravenous fluid, ibuprofen, gabapentin, and oxycodone. The patient was cleared for discharge home.

The patient presented with pain, stable vital signs, an unremarkable physical examination, unremarkable ultrasound and CT scan, and an unremarkable laboratory evaluation except for a possible urinary tract infection (UTI).  Treatment of UTI does not require hospital admission nor does pain control.  Once the providers ascertained that there was no evidence of a serious medical condition, the patient could have been sent home on oral antibiotics and pain medication.

Note that there was no evidence of acute pyelonephritis that needed hospital stay.

 The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.
The continued inpatient admission was not medically necessary.

The carrier's denial of coverage for the continued inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Relapsed IgA Lambda Myeloma.
Treatment:  Inpatient level of care services.

The insurer is denied coverage for inpatient level of care services.  The denial is overturned. 

This is a female patient history of IgG Lambda Myeloma and acute kidney failure.  The patient had relapsed IgA Lambda myeloma, requiring radiation therapy from T8-S1 followed by CyBorD and RVD chemotherapy.  The patient had an excellent response; however, she relapsed, evinced by positron emission tomography (PET) scanning.  The patient was admitted for high dose chemotherapy and stem cell collection.  She received infusion Cytoxan, Cisplatin and Etoposide with Intravenous therapy (IV) Decadron daily for four days.  Each daily infusion took almost a day to be administered.  The patient required constant intravenous (IV) hydration and close monitoring of blood counts and chemistries.  The patient had a history of acute kidney failure.  The patient developed severe distress and psychiatry assisted.  When the patient's nausea and vomiting were under control on an oral regimen, the patient was discharged.

As per Kumar, et al (2020), "The NCCN Guidelines for Multiple Myeloma provide
recommendations for diagnosis, workup, treatment, follow-up, and supportive care for patients with monoclonal gammopathy of renal significance, solitary plasmacytoma, smoldering myeloma, and multiple myeloma."  And according to Laubach et al. (2016), "The prognosis for patients multiple myeloma (MM) has improved substantially over the past decade with the development of new, more effective chemotherapeutic agents and regimens that possess a high level of anti-tumor activity.  In spite of this important progress, however, nearly all MM patients ultimately relapse, even those who experience a complete response to initial therapy.  Management of relapsed MM thus represents a vital aspect of the overall care for patients with MM and a critical area of ongoing scientific and clinical research."

Based on the review of the medical record and literature, inpatient level of care was medically necessary for this patient.  The patient was getting high volume of intravenous (IV) fluids and daily infusions of three chemotherapy drugs over 22 hours.  This was high dose chemotherapy.

The patient required constant monitoring of her blood counts and chemistries.  The patient was at high risk for pancytopenia, renal failure and intractable nausea/vomiting.  This treatment regimen is not typically done on an outpatient basis.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient level of care services is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease 
Treatment: Inpatient admission 
 
The insurer denied the inpatient admission. The denial was upheld. 

This is a male patient with a medical history of prior tobacco use, coronary artery disease, status post ST-elevation myocardial infarction, percutaneous coronary intervention with drug eluting stent, hypertension, hyperlipidemia, and diabetes mellitus. The patient presented to the Emergency Department (ED) with complaint of worsening episodes of mid-sternal chest pain. The patient underwent cardiac catheterization via right radial access. This revealed severe stenosis of the right coronary artery, for which two drug-eluting stents were placed. There were no procedural complications. The patient was admitted to the Telemetry unit for continuous cardiac and post catheterization monitoring. The patient was ambulatory and tolerating oral intake. After treatment, the patient was cleared for discharge home with instructions for outpatient follow-up. 

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this procedure is an outpatient one. In this case, the clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate. There were no extenuating circumstances in this case which warranted inpatient admission status following elective cardiac catheterization and attempted angioplasty. The patient could have been monitored at the observation level of care after the procedure. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Pneumonia
Inpatient hospital

The patient is a male who presented to the emergency room with the chief complaint of right lower quadrant abdominal pain present for 2 weeks and fever. Pain was intermittent and occasionally radiated to the right buttock. Over the previous 5 days, he also complained of increased frequency of urine with malodorous urine. He stated that his fever had been as high as 102.8. He denied any nausea or vomiting. He denied any cough or shortness of breath. His past medical history was significant for a ruptured appendix treated with intravenous (IV) antibiotics a few years prior to his present emergency room (ER) visit. On examination in the emergency room, his temperature was 100.3 F, heart rate 92, respiratory rate 17, and oxygen saturation was 100% on room air. Blood pressure was 118/76. Cardiac and respiratory exam were normal. Abdominal exam revealed the abdomen to be soft, non-distended with no rebound tenderness. There was some right lower quadrant moderate tenderness and mild diffuse tenderness in all other quadrants of the abdomen. There was no guarding. Bowel sounds were normal. The rest of his physical exam was normal. An admitting diagnosis of acute kidney injury and acute viral syndrome was made and the patient was admitted to the hospital.

The health plan's determination is upheld. The inpatient stay was not medically necessary. There was no indication that the patient required an inpatient hospital admission. The patient had improved significantly in terms of abdominal pain. He was felt to have community acquired pneumonia which should have been managed as outpatient. This patient did not have any evidence of urine infection. The CT abdomen done in the ER did not suggest that he had acute appendicitis. It was felt that the mass in the Right lower abdomen was an enteric cyst. Surgery could have been consulted in the ER as he had some tenderness in the right lower quadrant of the abdomen.
Appeal type: Experimental/Investigational
Decision: Upheld

This male patient has diagnoses to include status post left basal ganglia stroke and Moyamoya disease.  He underwent bilateral pial synangiosis and subsequently developed bilateral middle cerebral artery (MCA) territory ischemic strokes, with resultant left spastic hemiparesis and right arm dystonia.  The provider states the patient is now able to walk independently with a left ankle-foot orthosis (AFO).  However, despite sustained traditional therapies including modalities such as dynamic bracing and electrical stimulation, he has a severely weak left upper extremity, with 1-3/5 strength, limited by fatigue and resistance.  This lack of function in his left arm has forced him to be fully reliant on his weakened right upper extremity.  A myoelectric prosthesis is being requested, with elbow, wrist, and hand/finger components.  

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.  A standard prosthesis (body-powered, hybrid) can safely and adequately address the patient's needs.  The scientific literature does not support such improvements, with use of a myoelectric hand prosthesis.  This is a convenience item above standard prosthesis use, and cannot be supported.  Therefore, procedure code L8702 (Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated) is not considered more beneficial for this patient's diagnosis, based on scientific evidence in peer-reviewed literature.

Per Willigenburg, N. W., McNally, M. P., Hewett, T. E., & Page, S. J. (2017), "RTP integrating myoelectric bracing may be more beneficial than RTP only in improving self-reported function and perceptions of overall recovery.  We observed no changes in the range of elbow extension, and no relationship between self-reported improvements and changes in reaching kinematics."
McCabe, J. P., Henniger, D., Perkins, J., Skelly, M., Tatsuoka, C., & Pundik, S. (2019), "In a group clinical setting, it was feasible to implement a myoelectric upper limb orthosis with chronic stroke survivors.  Clinically important and statistically significant gains were made on a measure of upper limb motor control.  The results may be explained by the motor learning based functionality of the device.  Further study is warranted in a larger cohort."  A standard prosthesis (body-powered, hybrid) can safely and adequately address the patient's needs.  Therefore, this patient is not a good candidate for procedure code L8702 (Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated).

The carrier's denial of coverage for procedure code L8702 (Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated) should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

This case involves a male who suffered a right middle cerebral artery (MCA) territory ischemic stroke and now has an essentially non-functioning left arm.  The patient is noted to be left-hand dominant.  He has participated in continuous traditional occupational therapy, as well as other modalities, which include static bracing and electrical stimulation.  The total loss of the myriad functions of the patient's left arm including bimanual dexterity indicates the patient's clinical presentation was equivalent to a left upper extremity amputee fully reliant on the right arm for completion of activities of daily living.  The patient has 1-3/5 strength in the left upper extremity.  The documentation detailed that despite some sustained progress, the patient does require the use of a left ankle-foot orthosis (AFO) and walk aid to effectively ambulate.   He has been referred to be evaluated for and ultimately fitted with a myoelectric orthosis which will restore his left arm range of motion and function.  The request was submitted for a powered upper extremity with a microprocessor and sensors.
This is a patient with persistent left hemiplegia after an MCA stroke.  Good recovery was obtained to the left lower extremity (LLE) and he can ambulate; however, despite exhausting most treatments, he has not made functional recovery of the left upper extremity (LUE).  The request for a myoelectric EWHO (MyoPro) (code L8702) is in hopes that it will restore arm function and range of motion.  There is no documentation that supports he has trialed this device and is able to actively use it for functional means.  Furthermore, although the Food and Drug Administration (FDA) approved the device, current literature is based on small studies.  Larger Randomized controlled trials are needed to establish safety and sustained improvement.  It is unclear whether there is health outcome benefit with this durable medical equipment (DME).  The requested device is not likely to be more beneficial than any standard health service.

The carrier's denial of coverage for procedure code L8702 (Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated) should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Left hemiplegia 

Treatment:  Procedure code L8702 (Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated)

The insurer denied coverage for procedure code L8702 (Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated).  The denial is upheld. 

This patient is a male diagnosed with ischemic strokes and resultant left hemiplegia.  He has poor left upper extremity function that reportedly has not improved with occupational therapy, dynamic bracing and electrical stimulation.  The medical literature cited by the manufacturer of this device was reviewed.  The quality and quantity of data in the current peer-reviewed scientific medical literature is inadequate to conclude the clinical utility, safety and efficacy of the requested L8702 (Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated) for the treatment of this member's clinical condition.  The studies provided are plagued by limited sample size, lack of control group, and retrospective.   
From a physical medicine and rehabilitation/pain management perspective as well as within a reasonable degree of medical certainty:  The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome for the requested device, in this particular case.  The procedure code L8702 (Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated) has not been proven to be the best available treatment for this patient at this time.  This device is not likely to be more beneficial than any standard treatments/procedures.	

The carrier's denial of coverage for procedure code L8702 (Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated) should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use disorder 
Treatment: Inpatient admission
The Inpatient admission was medically necessary for this patient.

The requested benefit of inpatient detoxification and withdrawal management and other medical services 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 on a daily continuous basis 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 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's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms (tremor, sweats, nausea and diarrhea, anxiety, irritability, restlessness and insomnia) which were being effectively addressed with Librium and supportive measures. The patient had associated clinical features that included lack of sober supports and impaired judgment and poor control of impulses. Thus, the adult inpatient stay and continued detoxification treatment of this patient's substance use disorders did necessitate the admission and continued structure of an inpatient level setting with withdrawal management and psychosocial supports, and 24-hour monitoring. 

The patient's history of substance use (frequency and quantity) together with the severe psychosocial stressors and functional impairments do reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification from alcohol use disorder 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/Guidelines-referenced below.

The requested benefit of Inpatient admission is clinically appropriate, medically necessary and warranted, and is therefore a covered benefit in this case scenario. The admission and 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 consideration of ASAM Criteria and application of NY State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain and bilateral lower extremity. 
Treatment: Physical therapy services. 

The insurer denied coverage for physical therapy services. The denial is upheld. 

This patient is a female with reported back pain and bilateral lower extremity numbness. The patient also reported difficulty sleeping. Currently under review is the medical necessity of physical therapy services provided. The physical therapy treatment notes made available for review provide insufficient objective clinical information to support the medical necessity for the dates of service under review. The clinical records do not establish the medical necessity of continuing a structured out-patient physical therapy treatment program. 

There is no specific documentation of a functional physical impairment. The etiology of the patient's sleeping difficulty may have been due to emotional, underlying medical or environmental factors that are not necessarily amenable to physical therapy treatment or addressed in the clinical records. 

The health plan acted reasonably, with medical judgment or in the best interest of the patient in this particular case.  Physical therapy services were not medically necessary. 

Based on the above, the medical necessity for the physical therapy services provided is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Digestive System 
Inpatient Hospital 

Diagnosis: Abdominal Pain 
Treatment: Inpatient stay 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

This is a man with a history of hypertension (HTN), diabetes (well-controlled, Hgb A1c = 5.4), atrial fibrillation on oral anticoagulation, necrotizing fasciitis of the right abdomen (approximately 2-3 years prior to the current admission), and sleep apnea. He presented to the emergency department (ED) noting 1 week of left lower abdominal pain and firmness. He denied any associated fever or chills. The patient was evaluated by the general surgery service and the infectious diseases service. The general surgery consultant noted exam findings suggesting cellulitis of the pannus without evidence of abscess or need for surgical debridement. No bullae or necrosis are described. He was treated with broad spectrum intravenous antibiotics in the ED and was discharged home on oral linezolid per the recommendation of infectious disease (ID) consultant. 

Inpatient hospital admission was not medically necessary for this patient with cellulitis without evidence of systemic infection or sepsis (see response to question 1 above) Despite this patient's remote history of necrotizing fasciitis, his current presentation, based on physical examination, clinical course, laboratory results, and CT scan findings, was not suggestive of a necrotizing soft tissue infection. A lower level of care was appropriate.