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

Diagnosis: Substance Abuse
Treatment:Continued inpatient admission 
The continued inpatient admission was medically necessary for this patient.

The requested benefit of the continued inpatient admission 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 opioid/heroin together with daily use of a benzodiazepine anxiolytic (Xanax) and intermittent use of cocaine that did warrant 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 and from the date under review going forward.  Moreover, the patient presented with moderately severe withdrawal symptoms. The patient's social environment was not conducive to detoxification, and the patient struggled with withdrawal symptoms up until the time interval under review in the context of limited insight, impaired judgment and poor control of impulses.

Thus, the continued detoxification treatment of this patient's substance use disorder did necessitate the continued structure of an inpatient level detoxification setting and monitoring. The patient's history of substance abuse (frequency and quantity), and severe psychosocial stressors and functional impairments 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 the continued detoxification and withdrawal management were to have been continued 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 LOCADTR Tool that requires the patient in this scenario default to the higher level of care.

The requested benefit of continued inpatient admission is medically necessary in this case scenario. The patient's clinical features and treatment dimensions did warrant continued inpatient level detoxification services thru discharge and did necessitate the monitoring that is provided with inpatient level treatment including the use of comfort medications and seizure precautions. Moreover, the continued substance abuse detoxification treatment through discharge could not have been safely or effectively provided with lower level services as noted above. Thus, the continued inpatient admission should be covered in keeping with prevailing standards of care pertaining to substance use disorder services, including ASAM Criteria and the application of New York State OASAS LOCADTR 3.0 Criteria , referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
 
Treatment: Inpatient Admission

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

This case involves a teenage male who presented to the Emergency Department (ED) in mid-2018 with complaints of two episodes of vomiting and abdominal pain for eight hours.  The patient was noted to have right lower quadrant tenderness and mild rebound tenderness. The patient denied a past medical history. An ultrasound was performed and revealed appendicitis. The patient was admitted for surgical laparoscopic appendectomy, made nothing by mouth (NPO) and was given intravenous fluids and pain medication.  The patient underwent surgery without any post-operative complication. The patient was stable was discharged home the next day.  

Milliman Care Guidelines (MCG) notes that for patients with appendicitis, without abscess or peritonitis, the patient should undergo an appendectomy as an ambulatory procedure.  They further indicate that inpatient admissions are reserved for patients over 65 years of age or patients with toxicity, active comorbidities or an inability to arrange adequate outpatient support.  The patient was an otherwise healthy male who presented to the ED on in mid-2018 and was found to have acute appendicitis.  The patient was stable prior to surgical intervention.  The patient was admitted and underwent a laparoscopic appendectomy without complications.  Postoperatively, the patient was stable.  The patient could have undergone the procedure as an ambulatory procedure.  The patient had no active co-morbidities to support the necessity for inpatient admission.  The patient could have been placed on observation status and could have been observed post-operatively for any complications.  If complications were present, he could have been admitted at that time.

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

The patient is a male with a history of diabetes, hyperlipidemia, and hypertension who presented to the hospital. He presented with a chief complaint of flu like symptoms. He reported fevers, chills, and a productive cough for the past three days.

Vital signs showed temperature 37.2 Celsius, heart rate 105, blood pressure 112/76, and oxygen saturation 97%. On physical examination, skin was warm and dry, heart was regular, breath sounds were normal, abdomen was soft and mildly tender. Labs showed hemoglobin 7.9, white blood cell (WBC) count 7.9, hemoglobin 12.7, platelets 149, glucose 318, sodium 134, potassium 4.0, and calcium 9.2. Analysis of urine was mildly positive. Alanine aminotransferase (ALT) 325, aspartate aminotransferase (AST) 136. The patient was admitted with elevated liver enzymes. The plan of care included monitor liver enzymes, hepatitis studies, nothing by mouth (NPO), surgery consult, gastrointestinal (GI) consult, check thyroid function, check iron studies, and evaluation for other viral causes of hepatitis. There was some suspicion for acetaminophen toxicity versus autoimmune hepatitis.

Liver enzymes improved and studies for a bacterial infection were negative. The infectious disease service was also consulted and recommended continuing to hold antibiotics. A computed tomography (CT) of the abdomen showed liver steatosis and a magnetic resonance cholangiopancreatography (MRCP) confirmed these findings. The patient also underwent echocardiogram. Auto immune studies and infectious studies were negative or pending, and liver enzymes continued to decrease. He left against medical advice. The health plan's determination is upheld.

The inpatient hospital stay was not medically necessary, based on the available documentation. The reason is that the patient was not hemodynamically unstable, did not have evidence of bacteremia or abscess, had no fever, did not have hepatic encephalopathy, and was not septic. He had a stable presentation and was primarily undergoing diagnostic studies during the hospital stay. The patient was not acutely infected and had no need for a surgical intervention or other invasive intervention. He needed close monitoring to confirm that liver enzymes were improving but had no hepatic encephalopathy or coagulopathy. CT imaging was also negative for acute findings. In addition, he was hemodynamically stable, and the infectious disease service recommended no antibiotics. Overall, he had a non-acute presentation. He could have been managed at a lower level of care safely and effectively.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female accompanied by her mother to the hospital for abdominal pain that began the night prior at 6pm. Pain was 9/10, non-radiating, sharp, constant. The patient was also complaining of vomiting x 8 non-bloody non-bilious (NBNB), sweating, chills, headache. Denies diarrhea or constipation. No fevers at home. Mother gave Tylenol x2 for pain, which did not help. The patient admits to having similar pains 2 months ago that were less severe and resolved without intervention. The day prior to admission she had loss of appetite, tried taking some soup in the early evening, went to the bathroom to vomit and had a syncopal episode with loss of consciousness (LOC) 1 min; mother observed she did not hit her head. Denies vaginal bleeding or discharge. The patient was sexually active one time 4 months ago, was tested for pregnancy and sexually transmitted infection (STI) all negative.

Ultrasound showing 6 millimeter (mm) appendix, followed by CT showing normal-sized appendix without signs of inflammation. Surgery team ruled out appendicitis. On the floor, patient's vitals were monitored as per floor protocol. Patient was started on maintenance intravenous fluids (MIVF) dextrose 5% with 1/2 normal saline (D51/2). She received Tylenol as needed (prn) fever, Zofran prn nausea/vomit, warm pack/Tylenol 480mg/Toradol 15mg for pain. Per surgery notes "given repeated emesis and CT findings of normally-sized appendix without signs of inflammation, more likely represents gastroenteritis.". Obstetrics/gynecology (OB/GYN) was consulted rule out ovarian torsion versus (vs). pelvic inflammatory disease (PID). Pelvic ultrasound and reviewed by GYN stating that low suspicion for PID and ovarian torsion given clinical picture and pelvic ultrasound images. The patient was tested for Chlamydia and gonorrhea. On the day of discharge patient remained afebrile, vital signs stable. The patient appeared hydrated and active. She was well appearing and eating well with good urine output. Results for chlamydia and gonorrhea still pending, will follow up with mother. Both patient and mother verbalized understanding. Stable for discharge home. Patient was instructed to follow up with her primary medical doctor (PMD) 1-2 days after discharge.

The health plan's determination is upheld.

The requested health service/treatment of inpatient hospital stay was not medically necessary for this patient.

At the outset, she was evaluated, and her condition was not likely to be appendicitis at that time as CT scan of the abdomen that was done was equivocal and physical exam was not convincing. Admission assessment was "likely gastritis/gastroenteritis. Admission for abdominal pain." Her care would be expected to include IV analgesics and intravenous fluids (IVF). She had stable vital signs, normal laboratory studies therefore deterioration or the need for highly specialized or skilled care would be unlikely in this case. For these reasons, inpatient level of care was not necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for diabetes and obesity which impairs her mobility. A total of 11 hours a week personal-care services is requested. Patient is currently receiving 6 hours a week. The services were denied based upon medical necessity. The issue under review is the medical necessity of 11 hours per week of Consumer directed personal assistance services.  The health plan's determination is upheld.

The patient lives in her residence with her husband and 10 children. The ages of the children are between 5 and 25. Previously 1 of her daughters was the designated personal-care assistant however, she has moved out. Her son took over the role.
The patient is independent with personal hygiene such as bathing dressing and toileting and bed mobility. The health plan denied additional hours stating stand-alone tasks and safety monitoring/supervision are not considered medically necessary.
The consumer directed personal assistant hours according to tasking is noted to be pre-filling medications and homemaker task such as housekeeping. All other tasks are noted to be independent by the patient.
The patient was able to move independently. On the day of evaluation, she was out to visit family at the hospital, she was able to walk up the steps with no assistive device. Since the patient required no other services other than housekeeping and pre-filling medications, these services can be performed within the hours provided. Additional service hours are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Diabetic Ketoacidosis
Issue under review:  Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

This patient had mild diabetic ketoacidosis.  Patients with ketoacidosis can be safely managed in observation units unless they present with severe alteration of mental status or with critical illness (such as sepsis) [1].  This patient did not have alteration in her mental status and responded quickly to intravenous hydration and insulin therapy.  The documentation indicates the patient presented with tachycardia but does not support that she had severe dehydration that failed management under observation status.  She was hemodynamically stable with a normal blood pressure.  She had a history of daily alcohol intake, but she did not have evidence of alcohol withdrawal.  Therefore, no, the requested inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This case describes a male patient who underwent elective left total hip arthroplasty surgery. The patient had no complications and had an uneventful hospital stay. He was deemed stable for discharge on hospital day 3. The health plan has denied the inpatient admission as not medically necessary. The health plan's determination is upheld. 

There was no documentation of complications of the patient's total hip replacement surgery. The patient had an uneventful post-operative course and progressed well with the guidance of supervised therapy after surgery. The medical necessity of the inpatient stay is not justified in the provided medical records. In addition, the current, peer-reviewed orthopedic literature, including articles published by Nelson and colleagues in the Journal of Arthroplasty and by Pollock in the Journal of Bone and Joint Surgery supported the safety and efficacy of outpatient total hip arthroplasty.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic Bilateral Breast Hypertrophy

Treatment: Reduction Mammoplasty

The insurer denied the Reduction Mammoplasty. The denial was reversed.

This is a young female currently diagnosed with symptomatic bilateral breast hypertrophy.  The letter of medical necessity from early 2018 noted that the patient was to undergo bilateral breast reduction mammoplasty to remove 300 grams per breast in order to alleviate symptoms. Documentation from early 2019 noted that the patient was still very uncomfortable despite weight loss.  The patient continued to suffer due to brassiere (bra) strap grooving, back pain, intertrigo, headache, breast pain, and neck pain.  The patient had a current bra size of 36 DD.  She has tried conservative measures such as support bras and powders and creams that have provided no relief.  With diet and exercise, the patient successfully lost 20 pounds and kept it off for 6 months.  However, the patient notes that her anatomy in question has not decreased despite the change in weight. This patient was an excellent candidate for bilateral reduction mammoplasty to alleviate symptoms. 
 
According to medical literature, symptomatic breast hypertrophy is defined as a syndrome of persistent neck and shoulder pain, painful shoulder grooving from brassiere straps, chronic rash on the inframammary fold and/or frequent episodes of headache, backache, and upper extremity peripheral neuropathies caused by increase in the volume and weight of breast tissue beyond normal proportions. Medical literature indicates that treatment with reduction mammoplasty currently offers the best approach to symptomatic relief and constitutes the most common therapy for symptomatic breast hypertrophy as there is no lasting non-operative treatment for female symptomatic breast hypertrophy. Specifically, orthotic brassieres may offer some relief, but often substitute increased discomfort in the shoulders through pressure created by the straps. The aim of breast reduction surgeries is to eliminate the symptoms caused by excessive weight of the breast tissue and research has shown that breast reduction surgery has significantly improved pre-surgical complaints to include shoulder pain, shoulder grooving, intertrigo, headache, hand numbness, upper/lower back pain, neck pain and breast pain.

Based on the above, the medical necessity for reduction mammoplasty is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypokalemic, Hypomagnesemic, Hypophosphatemic	
 
Treatment: Inpatient Hospital Admission

The insurer denied the Inpatient Hospital Admission. The denial was reversed.         

This is a middle aged female patient who presented to the Emergency Department (ED) for evaluation after a sustained a fall with facial trauma. She received sutures for a laceration to the upper lip. At that time, she revealed that while at home she had an unexplained episode of chest pain, palpitations and shortness of breath the night before. She has a medical history of stage 4 colorectal cancer, and a Deep Vein Thrombosis (DVT).  While in the ED, she was found to be severely hypokalemic, hypomagnesemic and hypophosphatemic. She was started on intravenous (IV) hydration and electrolyte replacement and was appropriately admitted to a telemetry unit.

In "Hypokalemia: A Clinical Update", Kardalas, et al. state: "In cases of severe/symptomatic hypokalemia and cardiac complications, IV administration with continuous ECG monitoring is recommended."  This patient had moderate to severe hypokalemia with a recent fall possibly due to weakness (symptomatic hypokalemia) and a recent episode of symptoms that suggest cardiac etiology (chest pain, palpitations and shortness of breath).  Furthermore, a member of the medical team noted a prolonged QTc interval on her ECG.  Hypokalemia, as well as hypomagnesemia, is a well-established risk factor for QTc prolongation, as is female sex and this can predispose to torsades de pointes, a potentially lethal dysrhythmia.  

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

Diagnosis: Mood disorder
Issue under review: Continued inpatient mental health residential treatment

Determination:
The Continued inpatient mental health residential treatment was not medically necessary.

The patient's condition remained basically unchanged throughout his stay. The medical records do not reflect out of control behaviors or imminent danger to self or others which would require 24-hour daily confinement, observation, and treatment. This is further evidenced by consideration of plans to discharge the patient to a wilderness program.  The records indicate that the patient was safe for discharge by the date of service under review, but his mother refused to take him home pending long term placement. Thus, the days under review were due to placement issues, rather than clinical necessities at the current level. Based on the documentation reviewed, the health plan's assertion that, "care and recovery could continue care in the mental health partial hospitalization program setting," is correct.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a history of coronary artery disease, hypertension and diabetes who presented to the emergency department with abdominal pain, nausea and vomiting. On presentation, the patient had a temperature of 97.9, pulse rate of 90, blood pressure of 164/97, respiratory rate 18, and oxygen saturation 97% on room air. Blood work was notable for white blood cell (WBC) count of 8.4, hemoglobin 15.4, and hematocrit 47.0, platelet count 209,000, sodium 139, potassium 4.1, chloride 107, and bicarbonate 27, total bilirubin 0.3, alkaline phosphatase 70, aspartate aminotransferase (AST) 21, alanine aminotransferase (ALT) 19, and albumin 4.4. Abdominal ultrasound was notable for fatty liver. Computed tomography (CT) of the abdomen revealed mild circumferential thickening of the terminal ileum. The patient was admitted to the medical floor and treated with conservative management with intravenous fluid hydration, antiemetic therapy, and pain control. Gastroenterology service consulted. The patient did improve during the hospital course and ultimately was discharged with outpatient follow up. The health plan's determination is upheld.

This patient presented with abdominal pain and change in bowel habits of chronic nature as it has been over 6 months or so.  In fact, for the patient's symptoms a colonoscopy had reportedly been performed within the last year which was abnormal though the patient did not recall the findings and admitted that he had not follow-up as recommended for further evaluation and management.  During the index admission, the patient underwent CT abdomen/pelvis which revealed terminal ileal thickening and was conservatively managed.  He did not undergo endoscopic evaluation or require surgical intervention.  He was not treated with a prolonged antibiotic course.  Given the clinical presentation and radiographic findings, the patient either had an infectious, inflammatory or ischemic process resulting in the CT findings.  Given the time course, inflammatory is most likely with the differential including Crohn's disease.  The patient was hemodynamically stable on presentation and throughout the hospital course and therefore could have been managed at a lower level of care with ultimate review by Gastroenterology of prior records and repeat evaluation as necessary.  If the patient is found to have inflammatory bowel disease he would be treated as such with the appropriate medical therapy.  For these reasons, an acute level of care and inpatient admission was not medically necessary for treatment of this likely inflammatory small bowel process.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bipolar disorder with psychotic features, depression
 
Treatment: Inpatient mental health treatment, medication, monitoring

The insurer denied the continued inpatient mental health treatment. The denial was reversed.

This female presented to the ER due to medical issues including new onset of shaking, and was transferred to the psychiatric unit for worsened depression. She had a history of end-stage renal disease and was receiving dialysis, a diagnosis of Bipolar Disorder with psychotic features, a history of multiple past psychiatric hospitalizations, and a history of non-compliance. She remained disorganized, depressed and irritable, with difficulty responding coherently until discharge. 

The chart notes provided enough specific evidence to support that she was still disorganized, depressed and unable to care for her basic needs until discharge. The APA Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate, and also that patients with severe agitation, aggression, psychotic symptoms, suicidal or homicidal plan or intent or attempts, manic episodes, severe major depressive episodes, or inability to adequately care for basic self-care needs are in need of hospital treatment. 

This patient was still disorganized and unable to respond coherently until discharge, so she was still considered unable to adequately care for her basic needs. She had depression and multiple medical issues and still required inpatient hospital treatment. 

Based on the above, the medical necessity for the continued inpatient mental health treatment is substantiated.  The insurer's denial is reversed.