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

Orthopedic/Musculoskeletal
Home Health Care

The patient is a female with deformity and chronic pain related to previous extensive surgery of the lumbar and thoracic spine in the setting of spinal stenosis with resultant radiculopathy, myelopathy and neuromuscular dysfunction of the bladder. The patient also has history of peripheral vascular disease, chronic kidney disease, urinary incontinence, anxiety and hypertensive heart disease. The patient had been hospitalized with urinary tract infection (UTI) and weakness. Following her admission, she was transferred to rehabilitation. The patient desired to return to home with PCA services. The patient had assessment tool performed showing no change in need for assistance with tasks of meal preparation, ordinary housework, shopping, bathing and dressing UE/LE. The patient had worsening need for assistance in the tasks of managing finances, phone use, stairs, transportation and personal hygiene. The patient's primary physician wrote a letter that it was necessary for the patient to have PCA services 12 hours/day, 7 days/week to total 84 hour per week. The patient's son provided a letter stating that he was not present for the assessment and the patient was not able to ambulate 150 feet. The patient was using wheelchair for ambulation and had to self-propel which was difficult with her chronic spinal issues. The assessment tool indicated limited assistance needed with walking, locomotion and transfer to toilet. Patient's neck and thoracic regions are deformed causing her not to be able to raise her head or move side to side normally. The son also noted the patient needed help getting in and out of bed and was not able to do this alone (assessment noted the patient was independent with bed mobility). The health plan has approved 35 hours per week. The subject under review is the medical necessity of 12 hours per day, 7 days per week for a total of 84 hours per week.

The health plan's determination is overturned.

Yes, the requested Increase to Personal Care Services, Level 2: Total of 84 Hours per Week (12 Hours per Day/7 Days per Week) is medically necessary. The patient's past medical history is outlined as above, and she has history of significant injury and multiple surgeries to her spine in the past with resultant deformity with worsening functional status over the last year. The patient was hospitalized, and rehabilitation was recommended due to functional decline and patient wanted to return to home with PCA services. The assessment tool done 2 months ago does not seem to take into account the documented issues that patient has with walking, locomotion, bed mobility and toilet transfer. Her son was not able to be present for this evaluation. The assessment indicated the patient was able to walk greater than 150 feet without significant assistance. The patient's provider felt an increase in PCA services to 12 hours/day, 7 days/week to total 84 hours per day was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Treatment: Braces

The proposed braces are medically necessary.  The patient has a deep, impinging overbite that is causing severe soft tissue damage to his palate. This is an "automatic qualifier" according to the handicapping index scale. Orthodontic treatment is needed to correct this problem.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting; Diarrhea
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is a term male infant. He presented to the ED with two day history of diarrhea and two episodes of vomiting. An older sibling was sick with similar symptoms for about five days. There were no fevers, and his appetite was decreased. 

The patient's vital signs included temperature 36.9, heart rate 114, and respiratory rate 28 with 99% saturation in room air. Physical examination was significant for well appearance in no acute distress, moist mucous membranes, regular heart rate and rhythm, clear lungs, benign abdomen, non-focal neurologic exam, and brisk capillary refill. 

While in the ED, the patient was able to take two ounces of Pedialyte, but after an attempt to feed more, he vomited. At that point, IV fluids were started and labs were ordered. He was treated with two IV fluid boluses, and offered Pedialyte again, which he vomited thirty minutes later. Laboratory evaluation revealed metabolic acidosis (CO2 [carbon dioxide] 16) with normal glucose (75). He had total three episodes of vomiting in the ED, so the decision was made to admit for further management of dehydration. 

Admission orders included maintenance IV fluids and plans to slowly advance the patient's diet beginning with clear liquids in the morning. He was able to successfully tolerate advancing feeds and maintain adequate urine output. He was deemed stable for discharge to follow-up with his pediatrician in a couple days.

This previously healthy male infant presented to the ED with diarrhea followed by vomiting. In the ED, he was initially able to tolerate a Pedialyte challenge, but subsequently had three episodes of vomiting. Following admission, he responded well to fluids and was discharged the next day. While it was reasonable and appropriate to monitor him in the hospital for a longer period of time because of failure to tolerate multiple oral challenges, he was overall hemodynamically stable with no signs of significant dehydration, no underlying medical problems, and no indication of impending cardiovascular collapse or sepsis. He did not require acute inpatient admission. He could have been safely managed at a lower level of care, such as observation.
Appeal type: Medical necessity
Decision: Upheld

Breast Cancer
Radiation Therapy

This patient is a woman with a right breast carcinoma post lumpectomy. Proton Beam Radiation therapy is recommended to this right breast to decrease her risk of recurrence and the proton beam approach to deliver 3 treatments for accelerated partial breast irradiation is requested.

The health plan's determination is upheld. The proton beam radiation therapy is not medically necessary for this patient. Proton beam radiation therapy is not considered a standard approach of treatment for external beam accelerated partial breast irradiation for invasive breast carcinoma. There are not adequate medical literature published in peer reviewed journals supporting its use as equivalent nor better or safer than standard photon radiation therapy such as 3D conformal or intensity modulated radiation therapy (IMRT). There are studies ongoing looking at the efficacy and safety of the proton beam approach. There are very few small studies published that are reported to show potential improved normal heart and lung volumes exposed to radiation. Randomized studies with larger numbers of patients are needed to determine efficacy and safety of this approach of APBI. This treatment is not considered medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma Exacerbation/Bronchitis
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.     

This is a female patient who presented to the Emergency Department (ED) with complaints of wheezing, shortness of breath, and a non-productive cough for 5 days. It was reported that the patient had been to the Urgent Care Center the day before and was treated with oral steroids, Mucinex, Azithromycin and Advair. A chest x-ray was done which was negative for pneumonia. The patient reported coming to the ED because the patient had not felt better after being seen at the Urgent Care Center. Laboratory work up was performed and electrolytes were within normal limits, troponin was negative and white blood count was 12.1. A chest x-ray was performed which showed no infiltrates. The patient was admitted to the hospital for asthma exacerbation. The patient was treated with intravenous steroids, bronchodilator treatments, and magnesium. She tested positive for influenza and was treated with Tamiflu. She was discharged home on oral steroids. 

This patient did not need acute inpatient hospitalization.  Instead she could have been placed in Observation status while diagnostic testing and treatment were started. The patient improved after treatment in the ED.  The patient remained afebrile and hemodynamically stable.  She was not hypoxic.  There was no evidence of pneumonia or pneumothorax (PTX) on chest x-ray.  The patient was tolerating oral intake.  This patient could have been switched to oral medications after a period in observation which could be up to 48 hrs.  This patient could have been discharged home on Tamiflu, bronchodilator, and oral steroids with close follow-up in an outpatient setting.   

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

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

Diagnosis: Gastroenteritis 

Treatment: Inpatient admission 

The insurer denied coverage for inpatient admission. The denial is upheld. 

This patient is a female who presented with abdominal pain.  She reported swallowing a chicken bone the previous evening but denied dysphagia.  She also developed diarrhea which was not bloody.  She originally had a tachycardia in the Emergency Room (ER) but it resolved.  There was a low grade fever.  There was no abdominal rebound or guarding.  A CAT scan of the abdomen and pelvis was negative for acute pathology.  She was diagnosed with gastroenteritis.  She was treated with antibiotics and her symptoms improved.

MCG clinical indications for admission for Gastroenteritis (M-170) include having a severe infection such as bloody diarrhea, severe abdominal tenderness, hemodynamic instability, severe vomiting, severe dehydration, and an inability to maintain oral hydration.  The patient did not have these conditions.

The patient had gastroenteritis.  Intravenous (IV) hydration could have been given with observation status.  If antibiotics were felt to be necessary, she could have been given a course of oral antibiotics as an outpatient.  There was no evidence of any complication from swallowing the chicken bone.  The patient did not meet MCG criteria for admission for gastroenteritis.  

The healthcare plan acted reasonably and with sound medical judgment.  An inpatient admission was not medically necessary.  

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

Diagnosis: Herniated disc
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient is an adult female. She has history of obesity and herniated disc. She underwent L34 laminectomy and microdiscectomy. After surgery, the patient required IV Dilaudid PCA (patient controlled analgesia), and she was noted to have urinary retention requiring Foley replacement. The patient was discharged two days after surgery.

The patient had a new neurological issue (difficulty voiding) after a lumbar spine surgery. There are several possible causes for this, but acute inpatient level of stay is required to elucidate the cause of this neurological issue and appropriately manage it. This would not be appropriate in a lower level of care. The acute inpatient stay is medically necessary because of the urinary issues, as well as the requiring for IV PCA Dilaudid for pain because these issues could not be managed in a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Accidental Anticholinergic Drug Overdose 
 
Treatment: Inpatient hospital services 

The insurer denied coverage for inpatient hospital services. The denial is upheld. 

This patient is a male who took several doses of 50 milligrams of Benadryl 8 to 10 hours before presentation to emergency department (ED) for complaints of dizziness and palpitations. The vitals were Temperature afebrile heart rate 88, blood pressure 129/85,  oxygen saturation 100% on room air. The patient was treated with IV fluids in the ED. The EKG was normal. QRS 100 -120 ms. No Qt prolongation. The patient was admitted for cardiac monitoring and next day was discharged. The insurer has denied coverage for the acute inpatient admission. 

As per the ED note, patient did not have any altered mental status and not in distress. Later on during the emergency visit the patient had a heart rate of 120 beats per minute noted; IV fluids /bolus given. All labs including CBC, CMP< toxicology screen was negative. Heart rate continued to be in the 100s. Poison center called recommended 12 hours of observation. The patient was admitted to floor for cardio respiratory monitoring, and repeat EKGs. The dizziness resolved. The patient was discharged. 

This patient could have continued the treatment in observational status. Benadryl can cause anticholinergic toxicity. This patient had no altered mental status, the heart rate was not consistently elevated; the heart rate was responsive to fluids, there was no skin dryness, there was no QRS > 120 ms or R wave in aVR, there was no Qt prolongation. Furthermore, there was no need for antidote such as physostigmine or NaHCO3 bolus or drip. Also the amount of ingested Benadryl was small and 300 mg/72 kg is less than 5 mg/kg; the significant toxic dose is 20 mg/kg and above. The fatal Benadryl overdose cases were all intentional with self-harm intent. This patient took the pills to sleep. The patient also did not need any pressor support or any positive pressure for respiratory support. The patient did not require any fluid bolus while in the telemetry nor there was any documentation suggesting that patient had any perturbations in hemodynamic status while in the telemetry.  Due to the above facts, inpatient level care exceeds the medical necessity of patient. The patient could have been managed in an observational status. 

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

Diagnosis: Recurrent herpes
Treatment: Acyclovir Ointment

The treatment with Acyclovir is not medically necessary.

The patient is a female. She has recurrent genital herpes.  She uses oral Valtrex and topical acyclovir ointment for her outbreaks.

Vynograd et al found that an ointment containing flavonoids appeared to be more effective than both acyclovir and placebo ointments in healing genital herpetic lesions, and in reducing local symptoms.

Albrecht reports, "In general, there is no role for topical antiviral therapy in the treatment of genital herpes. Although topical agents (eg, acyclovir ointment) are available, they are of marginal benefit. In an analysis that compared the results of three randomized trials in patients with primary genital HSV, the clinical and virologic effects of intravenous and oral acyclovir were greater than topical treatment in reduction of viral shedding, time to complete healing of lesions, and reduction of new lesion formation. As an example, oral therapy reduced viral shedding by 80 percent, whereas topical therapy only reduced shedding by 55 percent; in addition, oral therapy reduced new lesion formation whereas topical therapy did not. In a separate study, there was no advantage of adding topical therapy to oral therapy."

In summary, there is no evidence that the use of topical acyclovir provides improved outcomes over the use of oral medications.  The medication does not provide any benefit.  It is not a standard of medical practice. Therefore, the standard of care in the medical and OBGYN communities would not consider treatment with Acyclovir to be medically necessary in this patient's scenario.

The treatment does not follow the accepted standard of medical practice and is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: 	 Cellulitis
 
Treatment:  Inpatient hospital services

The insurer denied coverage for inpatient hospital services.  The denial is reversed. 

This patient is a male child, who initially presented to an urgent care with a one day history of right knee swelling/erythema and 1 day history of fever.  It is noted that the lesion was drained in the Urgent Care (and sent to the labs for culture).  The patient was transported to the Emergency Department for further evaluation due to concern for a septic joint.  In the ED, patient was noted to be febrile to 101 degrees Fahrenheit.  The history records have him as having a prior MRSA infection the past year.  He was reported to have a limp for 1 day and pain on walking for 1 day.  Emergency department (ED) exam revealed right knee warmth and induration, right hip indurated with punctate lesion (another description was recorded as thus: Erythema on the right knee and a drained abscess is present, erythema with a papule on the superolateral half of the right thigh).  Blood specimen sent for laboratory analysis showed a WBC of 21.1k with a left shift (Neutrophils of 75.2), CRP 2.239 (0.0-0.9), ESR 29.  The patient received Clindamycin IV in the ED and was admitted for continued IV antibiotic treatment and further evaluation due to concern for septic arthritis or osteomyelitis.  The patient was admitted with cellulitis of the right hip and right knee.  Intravenous Clindamycin was continued. 

The patient was been monitored for the spread of erythema and fever.  Orthopedics was consulted and recommended weight bearing as tolerated on the right lower extremity, administering pain control as needed.  A CT scan of knee revealed abnormal soft tissue infiltration, edema versus hematoma, no evidence of knee joint effusion.  An ultrasound of the knee joint revealed (interpreted as) no evidence of abscess, extra articular soft tissue edema without joint effusion.  Infectious Disease also consulted and noted that the ultrasound revealed an abscess in the affected area and an incision and drainage was done.  Two to three drops were drained but were not sent for culture.  The recommendation was to continue intravenous Clindamycin and reassessing the patient.   Blood cultures were negative after 24 hours.  The patient was discharged after remaining afebrile, tolerating the switch from IV Clindamycin to Oral clindamycin to complete therapy as outpatient.  
                     
The admission meets Milliman Care Guidelines 23rd Edition criteria for an acute inpatient admission under the guideline for Pediatric Cellulitis.  This patient clearly had a cellulitis of an extremity (not just a wound).  The decision to deny was not in the best interest of the patient.  

Based on the above, the medical necessity for the inpatient hospital services is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse 

Treatment: Inpatient substance abuse treatment 
 
The inpatient substance use disorder treatment with detoxification and withdrawal management and stabilization was not medically necessary for this patient. 

The proposed inpatient detoxification treatment and other inpatient medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care.  The clinical features and indicated treatment dimensions of this patient's alcohol, cocaine and opioid use disorders, did not require or warrant 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 without sustained sobriety or abstinence from substances of abuse.  Moreover, the patient had been evaluated and cleared with regard to safety concerns, and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or general medical concerns that would have warranted an inpatient level admission and treatment.  His vital signs were normal and the withdrawal symptoms were scored at a minimal level at the time of admission. 

Thus, admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.  Any indicated treatment for substance use disorder in this case could have been provided, as clinically appropriate, at a lower level of care following the comprehensive assessment and stabilization at the time of intake. 

This answer is consistent with established practice guidelines, the scientific literature, and ASAM Criteria, as referenced below, and is entirely consistent with NY State instruction for this review including the appropriate application of the NY State OASAS LOCADTR 3.0 Criteria, referenced below.

The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could have been safely provided at a lower level of care in this case scenario.  The patient in this case presented with continuous daily use of alcohol and heroin and intermittent use of cocaine; he did not experience complications related to withdrawal during his brief stay or present with severe symptoms of a co-occurring psychiatric disorder, or abnormal findings on examination, or severe withdrawal symptoms, scoring a 3 (mild or light) on the CIWA scale for alcohol withdrawal and a 1 on the COWS scale indicating minimal opioid withdrawal.  His risk for withdrawal complications including seizures and delirium tremens were minimal considering his history, and he did not pose a safety risk that would have warranted the admission and continued inpatient level services and monitoring, as requested in keeping with NY State Guidelines and ASAM Criteria.