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

The patient was admitted to inpatient for detoxification from alcohol, stimulants, and benzodiazepines.  The last several days of the admission were denied as not medically necessary.  The health plan's determination is overturned. 

The proposed inpatient services and detoxification treatment and withdrawal management for severe poly-substance use disorder and other services noted in the clinical summary could not have been safely or effectively provided at a lower level of care.  The 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 risks for medical complications such as withdrawal seizures or overdose due to the combined use of alcohol and benzodiazepines together with high doses of methadone.  Withdrawal symptoms were managed with tapering dosages of benzodiazepine, and methadone was continued and required monitoring, 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.  Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review with associated substance use disorder treatments, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.  The severity of the patient's condition could not have been treated at a lower level of care and, thus, met the LOCADTR guidelines for inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

The patient has a past medical history of chronic obstructive pulmonary disease (COPD), metastatic laryngeal cancer to lung and prostate (requiring G tube feeds), who presented to the emergency department (ED) with complaints of difficulty breathing. The patient had presented to the ED 1 week prior for similar symptoms and was treated with duo nebs, steroids, magnesium, and oxygen. 

The health plan's determination is overturned. The inpatient hospital admission was medically necessary because the patient has a history of COPD and was in an exacerbation. The respiratory status/ shortness of breath was worse/more extreme than baseline. The evaluation required an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Alcohol Detoxification
 
Treatment: Inpatient hospitalization for Alcohol Detoxification
The insurer denied the Inpatient hospitalization for substance detoxification treatment. The denial was modified.
This patient is a male was admitted to inpatient substance detoxification treatment in late 2018 for alcohol detoxification. He had withdrawal symptoms including sweats, tremors, joint pain, abdominal pain, sleeping problems, agitation, headache, teary eyes, and anxiety and had a CIWA of 10. He reportedly had at least 10 past treatment episodes including multiple past inpatient substance rehabilitation treatments and detoxification treatments. He also had depression and anxiety and had past psychiatric hospitalizations. He reportedly had medical issues including gastroesophageal reflux and asthma. He took Librium as a detoxification medication. He was stepped down to inpatient substance rehabilitation treatment in the later part of this admission.
The insurer denied coverage for inpatient substance detoxification treatment in the earlier part of this admission as not medically necessary treatment. They stated that he was not at risk of severe withdrawal and did not require 24 hour inpatient detoxification treatment then in the hospital and they recommended a less restrictive level of care. 
This reviewer disagrees with the decision to deny coverage during this time but agrees with the denial of days on the later days of admission. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that patient with life threatening or complicated withdrawal such as delirium tremens or withdrawal seizures are in need of inpatient substance detoxification. It also states that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  It also reports that patients using large amounts of alcohol are at a higher risk of having delirium tremens after cessation of use. 
This patient required the treatment received in this hospital for medical detoxification treatment during the earlier part of this admission. He was using large amounts of alcohol daily and was considered at high risk for life threatening withdrawal including delirium tremens. He also was using cannabis. He had a history of depressive symptoms and multiple past psychiatric hospitalizations. 
Based on the above, the denial of inpatient hospital services at the withdrawal and stabilization services level of care is modified.
Appeal type: Medical necessity
Decision: Upheld

The patient was admitted with the diagnosis of dehydration.The patient presented to the emergency department with a three-day history of vomiting and fever to 103, and a one week history of cold symptoms. He was known to be exposed to viral illness in daycare. Vital signs on presentation: temperature 101.4, heart rate 154, respiratory rate 32, blood pressure 114/72, and oxygen saturation 100% on room air.

The health plan's determination is upheld. The inpatient admission was not medically necessary. This patient had mild to moderate dehydration and required IV hydration, which could have been accomplished at a lower level of care. The patient's elevated HR was secondary to a fever and came down to normal with oral antipyretic treatment. The patient had normal lab studies. This patient's hospital stay did not meet any criteria for an inpatient level care. Observation for overnight hydration at a lower level of care would have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: inguinal hernia
Treatment: Inpatient surgical services
The insurer has denied inpatient hospital admission. The denial was upheld.

According to the patient's medical chart this is an infant male with a history of inguinal hernia and hydrocele. On 09/14/18, he presented to NY and Presbyterian Hospital for repair of a right inguinal hernia under general anesthesia.  The patient tolerated the procedure well, and he was subsequently admitted to the post anesthesia care unit (PACU) for overnight monitoring, and was then transferred to the floor. There were no complications. On 09/15/18, the patient was voiding, his diet was advanced to formula, his intravenous (IV) line was discontinued and he was discharged home in stable condition. 

This infant underwent a scheduled right inguinal hernia without complication, without significant co-morbidity, e.g. obstructive sleep apnea (OSA) or prematurity. According to MCG: P-1305 (ISC) Hernia Repair (Non-Hiatal), Pediatric, the goal length of stay for this procedure is ambulatory. Inpatient stay may be needed for:

-Emergent surgery: Patient with strangulated hernia, or other evidence of ischemia or infarction of hernia contents, may require continued inpatient care or anticipated parenteral treatments (eg, antibiotics), close monitoring, and repeat laboratory tests.

-Procedures performed in the immediate neonatal period (ie, birth hospitalization).

-Significant peritoneal adhesions complicating surgery: Peritoneal adhesions (eg, from prior abdominal surgery) can make subsequent abdominal surgeries longer, with higher risk of postoperative complications or slow recovery.

-Surgical complications: Hematoma, ischemic orchitis, wound infection, seroma, urinary retention, ureteral or bladder injury, intestinal damage, or other complications may require further inpatient stay and possible surgical intervention.

-Postoperative ileus: Ileus is more common in patients with incarcerated hernia.

-Active comorbidities (eg, renal failure, pulmonary disease, congenital heart disease).

This was an ambulatory procedure which includes overnight monitoring.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of pulmonary arterial hypertension due to scleroderma. The patient is oxygen dependent and is being treated with continuous subcutaneous infusion of treprostinil (Remodulin) as well as oral agents for pulmonary hypertension.

The health plan's determination is overturned. The Increase in Personal Care Assistance Services to 35 Hours per Week is medically necessary for this patient. This patient has severe pulmonary hypertension, with resting dyspnea and limitations in performing activities of daily living. The unavailability of adequate assistance would pose substantial risks for this patient: the possibility of sudden worsening of her pulmonary hypertension if the patient were to fall and dislodge her subcutaneous catheter; the risk of injury if the patient was to fall while trying to prepare meals or use the toilet unassisted; the risk of skin breakdown and infection if she were to be incontinent and unable to bathe and change her clothing; and the risk of venous thromboembolism (would could be fatal in the presence of underlying pulmonary hypertension) from prolonged immobility if assistance in ambulating were not available.
Appeal type: Medical necessity
Decision: Upheld

The patient has a past medical history of hypertension and diabetes admitted on 1/18/19 with chest pain that was at rest and with exertion. Vital signs were normal. A chest x-ray was normal. An electrocardiogram (ECG) was reported as not acute. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. There was not a severe catheterization related complication (i.e. severe bleeding, cerebrovascular accident (CVA)), or supporting evidence for an acute coronary syndrome such as elevated cardiac biomarkers or an abnormal ECG. As such, criteria for an inpatient level of care were not met. This patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nausea, vomiting and chest discomfort
Issue under review: Inpatient admission

Determination:
The inpatient admission was medically necessary.

The patient presented with an acute heroin withdrawal, abnormal ECG, prolonged QT interval and sinus bradycardia, as well as chest pain. The patient was at risk for malignant arrhythmias, as well as other complications of acute withdrawal. The patient required IV fluids and close monitoring. Given the presentation, as well as abnormal ECG in the setting of opiate withdrawal, she would not be an appropriate candidate for an ED chest pain observation unit. It would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vomiting and apnea

Treatment: Inpatient admission, diagnostic testing and monitoring

The insurer denied inpatient admission. The denial was reversed

This newborn presented after an episode of forceful emesis 15 minutes post-prandial associated with one minute of listlessness, pallor/cyanosis and appearance of apnea that self-resolved.  The infant's mother reported a similar incident occurred in the well-baby nursery on the day after birth.  Also, per maternal history, there was a previous infant who succumbed to sudden infant death syndrome (SIDS).  In the Emergency Department (ED), the infant's vital signs were normal, as was the physical assessment. 
  
The initial ED attending assessment included an impression of an apparent life-threatening event (ALTE) and to rule out intussusception.  An admission was undertaken with a concern related to the description of the event in the setting of a prior infant with SIDS.  The initial plan was for a sonogram (which was normal) and observation in the hospital.  Subsequently, there was an isolated maternal report of a brief episode of stillness and unresponsiveness that was not witnessed by any medical provider.  Following the event, there was documentation that the "newborn's lips are mildly cyanotic, her respirations were mildly tachypneic with a mild audible intermittent grunt." 
Following the sonogram, the patient was admitted to the pediatric floor for "observation X 24 hours."  The History & Physical (H&P) assessment included a brief resolved unexplained event (BRUE).  During the hospital stay, the infant remained asymptomatic.  

Although the providers admitted the patient for observation for 24 hours, an in-patient status was merited according to MCG:  P-12 Apparent Life Threatening Event (prior terminology for BRUE).
Appeal type: Medical necessity
Decision: Upheld

This patient with stage 4 chronic kidney disease (CKD), prior L (left) nephrectomy, and hypertension (HTN) presented to the emergency department (ED) with left lower back, flank, and epigastric pain for approximately 1 month. At the time of admission, her flank and low back pain were felt to be musculoskeletal in origin. 

The health plan's determination is upheld. The Inpatient Hospital Admission is not medically necessary for this patient. The record shows she had pain that was reproducible with movement. It shows she had chronic kidney disease and her kidney function was at baseline. She had no severe electrolyte abnormalities or hemodynamic instability. A CT scan of the chest, abdomen, and pelvis showed no serious underlying condition. She did not have peritoneal signs or require an urgent procedure. No serious condition was identified that could only be safely monitored or treated at the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: anxiety, depression, suicidal ideation, emotional dysregulation, identity confusion
Issue under review: residential mental health treatment
Summary: No, the proposed treatment, residential mental health treatment, was not medically necessary. 
There is nothing in the chart that indicates that, as of the beginning date of service under review, the patient required or could benefit from 24-hour daily supervision and treatment.  There were no acute safety issues.  This patient was dealing with significant unresolved family issues.  These issues could be best treated at a lesser level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Melena
Treatment: Inpatient hospital admission
The proposed acute level inpatient hospitalization was not appropriate and medically necessary for the management of this patient's clinical condition.
The patient presented with two-day h/o melena not associated with any abdominal pain, nausea, vomiting, and hematemesis and in the ED, he was hemodynamically stable. He was started on IV fluids and PPI infusion, GI was consulted, and he underwent EGD the next day which revealed non-bleeding duodenal ulcer, and gastritis secondary to H.pylori. His Hb/HCT remained stable and he tolerated full liquid diet well after the procedure.  The patient was deemed stable to be discharged home . Based upon this clinical scenario, the acute level care was not medically necessary, and the patient could have safely managed under lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, nausea and vomiting; High blood pressure
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

This patient had elevated blood pressure, but only mild elevation, without any signs of coronary ischemia, neurologic compromise or other end-organ damage.  He was treated with oral medication, and records also note that the admission was based on clinical trial requirements for monitoring and treatment of elevated blood pressure.  He had nausea, but no hemodynamic instability.  Also, no acute kidney injury or severe electrolyte disturbance was noted.  Given these considerations, he did not require acute care inpatient hospitalization.
Appeal type: Medical necessity
Decision: Upheld

The patient presented for detoxification services. The patient was using alcohol on a continuous daily basis together with crack cocaine, and Xanax. The patient has a history of bipolar disorder and post traumatic stress disorder with associated symptoms of anxiety. The patient had received multiple past substance use disorder treatments in the past. The health plan's determination is upheld.

In this case scenario, the patient was amenable to treatment with lower level care in a less restrictive setting. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and stimulant cocaine, and sedative-hypnotic-anxiolytic (Xanax). Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. There were no severe symptoms of withdrawal or biomedical issues in this case despite subjective complaints of withdrawal and vital signs were normal throughout the stay. The admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.  The New York (NY) State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria are not met for the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left renal colic; ureteral calculus
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
An acute inpatient level of care was not medically necessary.  Care could have been provided at a lower level of care.  The patient was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis.  Following admission, there were no unstable vital signs reported.  The patient did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. She did not have bilateral obstruction, acute renal failure, severe vomiting.  Pain control, IV antibiotics and IVF followed by ureteroscopic stone extraction and stent placement in a non-toxic patient can be provided at a lower level of care.  Stone surgery on the day after admission would have expedited the care provided and potentially shortened the hospital stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Scleroderma and associated esophageal dysmotility and GERD
Treatment: Brand Zegerid
Branded Zegerid is not medically necessary, based on the available records.
"... available records do not support an objective documentation of intolerance to specific PPIs, nor was her response to Zegerid OTC provided.  Neither history nor undue proclivity to respiratory embarrassment was documented.  Her esophagram neither supports aspiration nor transit delay of a barium pill such that her dysmotility may, per available record, be considered mild.  Further, her endoscopy confirms that her esophagitis is uncomplicated and of only moderate severity.  A therapeutic substitution in PPIs would not, based on available records, be expected to place the patient's health at undue risk so as to otherwise render as medically necessary only branded Zegerid in lieu of other PPI trials.
Charted documentation is not provided to support the patient's claim that she is intolerant to generic Zegerid (the patient states that she cannot tolerate silicon dioxide--a naturally-occurring environmental substance in water and food) or of past "vomiting, bleeding, aspiration" that the providers have objectively attributed to her intake of the generic drug in question, or to her direct ingestion of silicon dioxide.  The patient's complaint of "vomiting, bleeding, aspiration" was subjectively reported by her provider without supporting objective documentation in the provider's record.  Therefore, these symptoms could have at the time been due to many factors that had little to do with what Zegerid formula was then being taken. The patient's use of Zegerid started with Dr. Gutman in 2012, predating her current provider's office notes that don't list generic Zegerid as a patient intolerance. 
Documentation is not provided of confirmation that other medications taken at the time of reported "vomiting, bleeding, aspiration" were free of silicone dioxide.  Of note, there were multiple manufacturers that supplied Motilium and its generic domperidone to Canada when the patient procured this agent from outside FDA-control, under the recommendation by Dr. Gutman during the period 2012-2015."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Numbness and slurred speech
Treatment: Inpatient admission

The acute inpatient admission was not medically necessary.

The patient is a female who presented with the acute onset of numbness all over her body and slurred speech. At presentation, the patient had a normal neurological examination and vital signs.  Her computed tomography (CT) of the brain was negative.  She was evaluated by Neurology and was determined not to have had a transient ischemic attack (TIA). 

The patient's presentation was unlikely to be ischemic in nature (numbness all over her body). The clinical presentation was associated with low risk of recurrent ischemia and did not require acute inpatient admission. Evaluation, monitoring and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient has a class II malocclusion, bimaxillary protrusion, missing # 7, severe maxillary spaces and mild mandibular spaces, severe anterior open bite. The proposed treatment is braces to close spaces and restore # 10 by a general dentist as needed after braces with treatment time 24-30 months. The health plan's determination is upheld.

The requested treatment with braces is not medically necessary. The malocclusion in question does not meet the standard of care criteria used in most programs to be classified as handicapping, and therefore treatment would not be considered medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 20 with no auto qualifier present. Using these evaluation methods, a score of 26 or more would be required for treatment to be considered medically necessary.