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

Diagnosis: Low back pain; fever
Treatment: Inpatient admission
The inpatient admission was medically necessary.

The patient is a male whose inpatient admission is under review. The patient has a history of substance abuse, Hepatitis C, cirrhosis, liver, failure, psoriasis. He presented with severe lower back pain, pain non-radiating. The patient was a poor historian. He had no numbness, bowel/bladder incontinence. He had recent "blood infection" at an OSH (outside hospital) one month prior.

In the ER, the patient's vitals were as follows:  T (temperature) - 99.9, P (pulse) - 103, RR (respiration rate) - 19, BP (blood pressure) - 112/65. On general examination, the patient was non-toxic, intoxicated (writhing at one point). Examination of the patient's chest, CVS (cardiovascular system), abdomen, and back were normal. Examination of his skin revealed 3 cm wound on the left ankle.

The patient's labs were as follows:
WBC (white blood count) - 13.3 (high)
Hg (hemoglobin) - 12.1
Hct (hematocrit) - 35.3
Plt (platelets) - 60 (low)
Na (sodium) - 138
K (potassium) - 3.4 (low)
Cl (chloride) - 107
CO2 (carbon dioxide) - 23
BUN (blood urea nitrogen) - 8
Cr (creatinine) - 0.8
Albumin- 2.8 (low)

CT of the patient's abdomen/pelvis revealed fluid filled, mildly dilated mid small bowel loops (with question of enteritis), cirrhosis, portal HTN (hypertension), splenomegaly, stable inguinal LAD (lymphadenopathy) L>R (worse on the left).

The patient was admitted with history of IDU (intravenous drug use), history of recent bacteremia, with back pain, leucocytosis, and tachycardia. He was started on IV vancomycin and gentamicin and admitted. A workup included MRI of the spine to r/o (rule out) osteomyelitis/epidural abscess. In the end, no source was found other than potential infection left ankle, discharged and treated with PO (oral) Bactrim.


Given the patient's history of IDU, and recent history consistent with bacteremia, standard of care would dictate admission to r/o endocarditis, osteomyelitis, and abscess, as was done in this patient. That information notwithstanding, the patient still meets the initial criteria for IV treatment and admission for cellulitis/abscess given by the Infectious Diseases Society of America (1), as he had systemic signs of infection (leucocytosis and tachycardia). Thus, this admission was warranted, supported by IDSA guidelines, as well as standard of care. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance use disorder 
Treatment: Residential treatment Services 

Summary:
The patient is an adult female. She completed a detoxification and was referred for residential rehabilitation and substance use disorder treatment to address opioid (heroin); alcohol; and stimulant (cocaine and amphetamine) class substances. The patient has no history of withdrawal seizures or delirium tremens, but did report increasing blackout episodes. Again, she received detoxification prior to transitioning to residential rehabilitation level services with persistent withdrawal or post-acute withdrawal symptoms (PAWS) with craving at the time of transitioning to residential services. She has a history of poly-substance use disorder beginning in adolescence with more recent daily continuous use of heroin with IV administration of one bundle; and the use of alcohol with daily use of beer and liquor, and use of soft and crack cocaine (1-2 grams). The patient has a history of multiple treatment episodes. She reported eleven months of abstinence with no other periods of sobriety. 

The patient presented with substance use disorders with use of heroin, alcohol and cocaine/amphetamine. She received inpatient detoxification treatment transitioning to the residential level rehabilitation treatment. By the date of service in question, she had engaged in treatment with continued use of medication assisted treatment with Suboxone and her medications to address mood disorder and PTSD including medication for anxiety and insomnia (Gabapentin, Prazosin and Trazodone). 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 more positive interactions with staff and peers. From date of service in question 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 residential treatment services from date of service in question- forward is not met in this case scenario consistent with ASAM Criteria, the scientific literature and published guidelines, referenced below.
Appeal type: Medical necessity
Decision: Overturned in Part

Trauma/injuries:Other
Inpatient hospital

The patient is a male with a past medical history significant for cerebrovascular accident (CVA) with right-sided hemiplegia, hypertension, and benign prostatic hyperplasia (BPH) who presented to the hospital after he sustained a fall and stayed on the ground for an unknown duration. Because of expressive aphasia, the patient was unable to provide a detailed history. Based on the information obtained by the admitting physician, it looked like the patient stayed on the floor for a long time.

The health plan's determination is overturned in part. Care at the inpatient level of care was acceptable for 3 days for treatment of rhabdomyolysis and acute kidney insufficiency. This patient was admitted to the hospital after he sustained a fall and spent a long time laying on the ground. As a result of the fall, the patient developed rhabdomyolysis. His CPK level was abnormal at the time of admission. Rhabdomyolysis was affecting the patient's kidney function, and at the time of admission, the patient had some degree of kidney insufficiency and metabolic acidosis due to kidney insufficiency.the patient's rhabdomyolysis resolved and the patient did not require further administration of intravenous fluids.
At that time, it became clear that the patient's neurologic status was basically at the baseline, and the abnormalities on the neuro exam were chronic. The patient did not have any evidence of acute stroke.
At that time, he needed to be discharged to a rehabilitation facility, and social services were working on placement.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea 
Treatment: Hyoglossal nerve stimulation or Inspire upper airway stimulation system

The health plan should cover the Hyoglossal nerve stimulation or Inspire upper airway stimulation system.

Otolaryngology's academy's recommendations, as well as the literature, support that this procedure is the treatment of choice for OSA seen as seen in this patient (1-4).  He has the appropriate diagnostic findings and has not tolerated CPAP.  The procedure is not E/I, and it is accepted standard of care (1). 

The Hyoglossal nerve stimulation or Inspire upper airway stimulation system is likely to be more beneficial.

This individual has severe OSA, which is a potentially life threatening disorder.  The patient requires therapy and has not tolerated CPAP.  At this point, hypoglossal nerve stimulation is the only therapy that can be beneficial besides a tracheostomy, which has severe life-altering consequences.  As such, hypoglossal nerve stimulation is the best option.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea 
Treatment: Hyoglossal nerve stimulation or Inspire upper airway stimulation system 

The health plan should cover the Hyoglossal nerve stimulation or Inspire upper airway stimulation system.

The Hyoglossal nerve stimulation or Inspire upper airway stimulation system is likely to be more beneficial.

All records were reviewed.  The patient is a male with a history of OSA.  His AHI on sleep study was 51.6 with a BMI of 28.29.  The patient could not tolerate CPAP and underwent a sleep endoscopy where there was no complete concentric collapse at the velum.  The patient failed an oral appliance trial.  He has undergone a previous septoplasty and inferior turbinate surgery.  The provider is requesting placement of an Inspire hypoglossal nerve stimulator system to treat the patient's OSA.  

There is support in the literature for the efficacy of the Inspire hypoglossal nerve stimulator for the treatment of a subset of patients with OSA who have failed, or cannot tolerate, CPAP therapy.  

A prospective multi-center study documented a reduction of AHI out to 12 months.  In addition, there was a randomized, controlled withdrawal arm of the study which reported AHI reduction out to 18 months.  Therefore, based on current scientific literature, scientific evidence would support the efficacy of upper airway stimulation therapy with a hypoglossal nerve stimulator for a subset of patients with OSA who meet FDA criteria for the procedure.  In this particular case, the patient would meet FDA criteria for the device in terms of BMI, age, AHI and sleep endoscopy findings (there was no complete concentric collapse on sleep endoscopy).  The patient has had a previous septoplasty, inferior turbinate surgery and oral appliance therapy which did not eliminate the symptoms.  There was also a reported failed CPAP trial.  There would be no contraindications to the procedure based on the information provided.  Therefore, based on the information provided, the requested service is medically appropriate, as the requested health service or procedure is likely to be more beneficial than any standard treatment or treatments for the insured's condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea 
Treatment: Hyoglossal nerve stimulation or Inspire upper airway stimulation system 

The health plan should cover the Hyoglossal nerve stimulation or Inspire upper airway stimulation system.

The procedure and device are FDA-approved, as referenced below, and recognized in the treating community as efficacious and safe for properly selected patients.  This patient with severe sleep apnea and favorable anatomy is a good candidate for this intervention.  By virtue of review of the literature, it is neither experimental nor investigational which were the categories of exclusion in the plan policy.  This is particularly evident with the withdrawal study by Woodson, referenced below, which showed the efficacy of the therapy and the reversal of efficacy by discontinuing the stimulation.  

The Hyoglossal nerve stimulation or Inspire upper airway stimulation system is likely to be more beneficial.

For this patient, the proposed procedure is required to treat the sleep apnea, which is not controlled by more conservative measures.  He has failed both CPAP therapy and trial of oral appliance.  It meets the standard of care and is not for the convenience of the patient.

The principal specialty in Otolaryngology  (the American Academy of Otolaryngology- Head and Neck Surgery) has examined the scientific support for hypoglossal nerve stimulator in sleep apnea and concludes:

The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy (PAP).  Not all adult patients are candidates for UAS therapy and appropriate polysomnographic, age, BMI and objective upper airway evaluation measures are required for proper patient selection.  

This patient has had proper evaluation and meets clinical criteria for this intervention.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mild dry eye; keratojunctivitis,

Treatment: Punctal plug 

The insurer denied coverage for Punctal plug. The denial was upheld.

This patient is a female with chart notes indicating that the patient was following up after cataract surgery.  A note indicated that the patient noted mattering around the eyes in the morning.  The patient has a history of keratoconjunctivitis sicca.  The patient was taking Keflex and Maxitrol.  The patient was found to have mild dry eye.  Artificial tears were recommended.  Additional chart notes indicated that the patient was following up for a chalazion.  The patient was not using any ocular medications.  The patient was advised to "purchase and use high quality artificial tears." Although not documented in the treatment plan, from the ocular history, bilateral punctal plugs were placed.  It should be noted that on a specified date the patient had returned for follow-up of the keratojunctivitis, and the note states "this is only a minor nuisance for her and it bothers her rarely and remains problematic."

The same note states that the patient was advised to use a massing mask two times daily, start fish oils, and omega 3.  The patient was again instructed re: artificial tears.   There is no notation regarding whether the patient used artificial tears after a specified visit.  The patient was diagnosed with dry eye disease.  Artificial tears, omega 3 supplements, and massing mask were recommended on the same day the punctal plugs were placed.  Punctal plugs were denied because first line therapy had not been tried and failed.  

Punctal plug for date of service specified is not medically necessary for this patient.  Per the American Academy of Ophthalmology Preferred Practice Patterns (2018) stage approach to the treatment of dry eye lists 2 steps.  
Based on the documentation provided for review, there is no supporting evidence that the patient has failed step 1 therapy (artificial tears).  Therefore, punctal plugs with date of service specified are not medically necessary.

Per Ervin, A. M., Law, A., & Pucker, A. D. (2017), "Although the investigators of the individual trials concluded that punctal plugs are an effective means for treating dry eye signs and symptoms, the evidence in this systematic review suggests that improvements in symptoms and commonly tested dry eye signs are inconclusive."

Per Jones L. et al. (2017), "Reflecting on all available evidence, a staged management algorithm was derived that presents a step-wise approach to implementing the various management and therapeutic options according to disease severity."                                                         

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

The carrier's denial of coverage for Punctal plug for date of service indicated is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Bilateral periorbital edema and oropharynx edema

Treatment:  Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.  The denial modified.

This patient is a female who presented to the Emergency Department (ED) complaining of facial swelling and dyspnea.  The patient has a history of gastritis.  The patient also complains of dyspnea.  The patient's daughter noted swelling to the bilateral eyes and the patient did walk 4 blocks to the hospital.  On presentation the patient was in moderate respiratory distress with bilateral periorbital swelling and posterior oropharynx swelling.  The patient was moved into resuscitation immediately receiving epinephrine as well as Solu-Medrol, Benadryl, and Pepcid.  The patient's vital signs revealed a pulse of 129 bpm with respiration rate of 16.  The patient's blood pressure was 158/88 with 100% oxygen saturation on room air.  The exam revealed the patient could only speak in one-word sentences.  She was also noted to be tachypneic with diffuse rhonchi and diminished lung sounds at base.  It was recommended the patient undergo multiple laboratory and diagnostic studies.  It was recommended that the patient be admitted despite the bilateral periorbital edema and oropharynx edema improving after epinephrine.  

On hospital day 2 she was seen and examined.  She was noted to have normal vital signs.  She was in no acute distress.  She had not had any further episodes of swelling and was hemodynamically stable.  She was recommended to downgrade to the medical floor.  She was receiving diphenhydramine every 6 hours as well as famotidine every 12 hours and methylprednisolone every 8 hours.  The physician indicated the swelling had significantly improved.  She continued with care and did not have any further significant adverse events.  She was recommended to carry an epinephrine pen.  She was also recommended to follow-up with outpatient services from allergy immunology.  After further stabilization she was discharged with instructions to follow-up.

The admission is medically necessary.  The patient had anaphylaxis.  While this can occasionally be managed as an outpatient after a 6-hour period of observation in the ED, this patient had respiratory obstruction and low oxygen saturations, and admission was warranted.  Most patients will transiently improve with epinephrine, but there is a concern for recrudescence when the epinephrine wears off and of a biphasic reaction, which is a recurrence of the anaphylaxis without reintroduction of the allergenic substance according to literature findings.  Multiple doses of epinephrine (this patient received two) predict admission.  Therefore, 1-2 days of observation in a monitored setting is reasonable.  The request is modified to allow an inpatient stay of 2 days.

The carrier's denial of coverage for the inpatient hospital admission is modified.  Approve first two days of inpatient admission.  Deny third day of admission.
Appeal type: Medical necessity
Decision: Overturned

Substance Abuse/Addiction
Substance Abuse: Inpatient

The patient is a man who was admitted following medical screening to acute inpatient level services for monitoring and detoxification and withdrawal management of severe alcohol, stimulant (cocaine), cannabis, sedative-hypnotic-anxiolytic (benzodiazepine/Xanax), and opioid (heroin) use disorders. He was using up to 15 bags daily of heroin with IV administration, large amounts of alcohol per day with up to 5 pints of liquor, $10 worth of marijuana, $20 worth of crack cocaine, and 4 to 6 mg of Xanax. The patient had experienced mild to moderately severe alcohol/anxiolytic and opioid withdrawal at the time of admission with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 12 and Clinical Opiate Withdrawal Scale (COWS) scale score of 10. He had severe withdrawal symptoms in the past requiring detoxification services on multiple occasions including six treatment episodes since early 2019 and one three days prior to this admission. Additionally, he had received medication assisted treatment with Suboxone off and on, as well as using heroin and non-prescribed methadone. The health plan denied the inpatient treatment as not medically necessary. At issue is the medical necessity of the inpatient substance abuse treatment.

The health plan's determination is overturned. 

The inpatient treatment of this patient's substance use disorders did warrant the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorders with multiple substances of abuse, and the associated psychosocial stressors and impairment of functioning. Withdrawal symptoms were managed with tapering dosages of benzodiazepine and methadone requiring monitoring and as needed (prn) medications, as well as the availability of comfort medications and nicotine replacement and vitamin replacement therapy to prevent the onset of encephalopathy. Seizure and fall precautions were provided. Counseling and educational sessions with motivational techniques together with case management services were appropriately provided to motivate the patient's transition to rehabilitation substance use disorder treatment. Medical necessity for the admission and the continued inpatient services, is met in this case, and is consistent with prevailing standards of medical practice, published practice guidelines, and ASAM Criteria, referenced below. This answer and determination is also consistent with New York State instruction concerning medical necessity reviews including the appropriate application of the NY State OASAS LOCADTR 3.0 Criteria and Guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lenox-Gastaut Syndrome

Treatment: High Frequency Chest Wall Machine (E0483RRx3)

The insurer denied coverage for High Frequency Chest Wall Machine (E0483RRx3). The denial was upheld.

This patient is a male with developmental delay, seizures and a diagnosis of Lenox-Gastaut Syndrome. The child has had recurrent hospitalization for aspiration pneumonia in the past and is currently feed solely by gastrostomy tube. The child requires BIPAP when sleeping. The frequency of seizures has decreased since starting a ketogenic diet. The child also has the cough assist device in the home to help with mobilization of airway secretions. The last hospitalization was in mid-2018. Currently the child is only treated with the Vest approximately once per month for 2 or 3 days or once a day for 15 minutes when the mother assesses that the child is congested and needs additional therapy. The mother is anticipating getting a home nurse assigned in the near future to help with the child's ongoing care needs. There is no documentation of bronchiectasis or chronic changes on the child's chest x-ray.

The insurer has denied the continued approval of the Vest in the home. The healthcare plan acted reasonably and with sound medical judgment. The past medical history in the medical records submitted for this review indicates that the child has had multiple admissions in the past for aspiration pneumonia and that the child is currently NPO [nothing by mouth] and fed solely by gastrostomy tube. The frequency of seizures has decreased on a ketogenic diet. There is no documentation of bronchiectasis or a report of a bronchoscopy to document chronic airway infection and failure to clear airway secretions. The mother also has the cough assist device in the home and this is used rarely. In addition, the mother indicates that the Vest is rarely used during the warmer months of the year and the Vest is used regularly only when the child is sick approximately once a month for 2 to 3 days.

The medical record does not support the need for ongoing treatment with the Vest in the home. Based on the medical history and the normal lung exam, the High Frequency Chest Wall Machine (E0483RRx3) considered not medically necessary.

Based on the medical history and the normal lung exam, the denial for ongoing need for the Vest in the home is upheld. Based on the above, the medical necessity for the High Frequency Chest Wall Machine (E0483RRx3) not substantiated. The insurer's denial is upheld.