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

Diagnosis: Substance Abuse
 
Treatment: Inpatient Substance Detoxification Treatment

The insurer denied the Inpatient Substance Detoxification Treatment. The denial was reversed. 

This patient presented for inpatient substance detoxification treatment. His symptoms included tremors, nausea, abdominal pain, irritability and anxiety. He had a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score of 18. He had decades long history of drinking ounces of beers per day; he also reported cocaine use. He had multiple past inpatient substance detoxification treatments, and 2 past substance outpatient treatments; all without success. He was placed on a Librium treatment protocol for detoxification and was then discharged.

According to the LOCADTR, he did require 24 hour treatment as he continued to drink daily and use cocaine despite 4 past inpatient substance detoxification treatments, and 3 past inpatient substance rehabilitation treatments, and 2 past substance outpatient treatments. He also required and needed detoxification medication, Librium to modify withdrawal and prevent more severe, complicated, or life threatening withdrawal. It was unlikely that the patient would remain abstinent while still having withdrawal symptoms so he required the time in this treatment setting to stop withdrawals and decrease the chance that he would relapse again when not in this 24 hour setting and also to prevent possible life threatening withdrawal symptoms. It was not likely that he would stop drinking if not in a 24 hour inpatient detoxification setting and it was not reasonable that he could safely or effectively be treated in an outpatient setting. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required the entire inpatient admission.

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

Diagnosis: Substance Abuse
 
Treatment: Inpatient Rehabilitation

The insurer denied the Inpatient Rehabilitation. The denial was reversed.  

This is a male patient who was admitted to the hospital for inpatient substance rehabilitation treatment. He has a history of using cannabis daily. He was referred by the parole department. He had legal issues and past arrests for grand larceny and robbery. It was noted that the patient relapsed while in outpatient treatment. It was reported that the patient lacks coping skills for sobriety and needed to improve relapse prevention skills. While in treatment he attended individual and group therapy. He was safely discharged. 

The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient substance rehabilitation treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. These facilities provide a safe and substance-free environment in which residents learn individual and group living skills for preventing relapse.

According to the LOCADTR he met criteria for inpatient substance rehabilitation treatment as he continued to use substances despite treatment at a lower level of care as he relapsed while in treatment in outpatient substance treatment. This was evidence that he required a sober and supervised structured therapeutic inpatient treatment setting to give him the best chance of working on improving coping skills, better identify relapse triggers, and improve relapse prevention skills. He also reportedly lacked a sober support system.

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

Diagnosis: Substance abuse
Treatment: Inpatient admission

The inpatient admission was not medically necessary for this patient.

The proposed inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The treatment of this patient's substance use disorder did not require 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 with alcohol and use of cocaine and cannabis and co-occurring depressive disorder and general medical issues. 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/objective symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatment recently with knowledge of substance use disorder treatment protocols, as noted in the clinical summary. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with a past history of multiple treatment episodes, as noted. Thus, inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.

This answer is consistent with New York State OASAS LOCADTR 3.0 Criteria/Guidelines and with established practice guidelines, the scientific literature, and ASAM Criteria, as referenced below.

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 and no general medical complications or co-occurring disorders that would have warranted inpatient level services. 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. The admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were therefore not medically necessary in this case scenario, as the health plan asserts. NY State OASAS LOCADTR 3.0 Criteria/Guidelines are not met for the inpatient level of care, referenced below.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  PAPA syndrome
Treatment:  Ilaris
The proposed treatment is medically necessary. 

The patient has a rare condition.  The available data indicates that IL-1 blockage is effective for this condition.  According to UpToDate: Biologic agents blocking various cytokines have been used to treat these conditions.  Interleukin-1 (IL-1) blockade is effective in many of these disorders.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Papillary thyroid carcinoma
Treatment: Inpatient admission
The inpatient admission was not medically necessary.  The patient's care could have been delivered at a lower level of intensity than acute inpatient care.

This patient had total thyroidectomy, which, in uncomplicated cases, can be managed as outpatient surgery or observation. This patient had no complications in their surgical procedure and in the preoperative period.  There was no intervention consistent with acute inpatient care. Therefore, the inpatient admission was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a female who has a history of hip pain and low back pain. Her hip pain resolved after hip replacement surgery. Her low back pain remained severe. Her low back pain radiates across her low back and down to bilateral posterior thigh with occasional numbness and tingling. She underwent lumbar transforaminal injection at L5-S1 level, and lumbar medial branch nerve block with temporary improvement. Her physical examination was significant for straight leg raise (SLR) positive bilaterally. Magnetic resonance imaging (MRI) revealed grade 1 spondylolisthesis of L5 on S1, L4 on L5 retrolisthesis, right paracentral disc protrusion with slight mass effect on right S1 nerve, a diffused bulging disc with broad based right foraminal herniation causing mild to moderate right foraminal stenosis at L4-5 level, a progressive right lateral recess disc herniation with severe central and right foraminal stenosis at L3-4 level. This patient was recommended to undergo this new medical intervention named INTRACEPT. The INTRACEPT system was designed to ablate intraosseous nerve within the vertebral body for the treatment of low back pain.
The subject under review is whether the INTRACEPT procedure is likely to be more beneficial than any standard treatment for this patient.

The health plan's determination is upheld.

The proposed health service or treatment Spinal procedure (INTRACEPT) is unlikely to be more beneficial for the patient's disabling condition or disease.
The INTRACEPT system was designed to treat back pain from vertebral body by ablating intraosseous nerves. Review of the medical records did not reveal enough evidence that this patient has pain from her vertebral bodies. On the contrary, this patient responded well to the prior epidural injections and lumbar medical branch nerve blocks, which indicates facet joint arthritis and lumbar radiculitis are significant pain generators. Additionally, in the supporting study (1) submitted by her treating provider, it stated "The primary inclusion criteria included skeletally mature patients with Type 1 or Type 2 Modic changes on an MRI at one or more vertebral bodies from L3 through S1. Primary exclusion criteria included symptomatic spinal stenosis, disk protrusion greater than (>) 5 millimeter (mm), spondylolisthesis >2 mm at any level, or radiculopathy." In the other study submitted by her treating provider, (2) the inclusion criteria is a patient with isolated axial back pain of greater than 6 months, and exclusion criteria included spondylolisthesis, radicular symptoms et al. This patient's MRI report did not indicate any Modic changes, but it did reveal spinal stenosis, spondylolisthesis, and she has signs and symptoms consistent with lumbar radiculopathy. Given this patient's medical history and the current clinical evidence, this patient is not a candidate for this INTRACEPT procedure.

In summary, this procedure is not likely to be more beneficial for this patient than any standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a female with low back pain. The Intracept procedure targeting the basivertebral nerve for the relief of chronic vertebrogenic low back pain is proposed.
Treatments the patient has tried include medications and interventional pain procedures. Lumbar magnetic resonance imaging (MRI) by report describes multilevel degenerative changes, including degenerative disc disease.
The subject under review is whether the proposed procedure is likely to be more beneficial than any standard treatment for this patient's condition.

The health plan's determination is upheld.

No, based on the submitted clinical material, current standards of care and peer reviewed medical literature, the proposed procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
An industry-sponsored proof of concept study of seventeen patients concludes (in part) "Ablation of the basivertebral nerve (BVN) for the treatment of chronic lumbar back pain significantly improves patients' self-reported outcome early in the follow-up period; the improvement persisted throughout the 1-year study period." [2]
The methodology of "a randomized controlled trial designed to demonstrate safety and efficacy as part of a Food and Drug Administration-Investigational Device Intraosseous Basivertebral Nerve Ablation for the Treatment of Chronic Low Back Pain Exemption trial" states (in part) the intention of the study is to demonstrate safety and efficacy of an investigational device. [3]
An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy issued by the North American Spine Society state (in part) "There is an insufficient evidence to make a recommendation for or against the use of percutaneous electrothermal disc decompression in the treatment of patients with lumbar disc herniation with radiculopathy." [4]
Reliable evidence shows that the consensus among qualified objective experts regarding the inherent nature of the Intercept spine procedure is that further clinical studies, clinical outcomes research, or clinical trials are necessary to determine its safety, efficacy and anticipated outcomes as compared with the standard means of treatment or diagnosis of the condition in question.
Therefore, the procedure is not likely to be more beneficial for this patient than standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a female with left hip and lower back pain. She has a prior history of left hip replacement. The patient has received multiple prior injections in the past, including epidural injections as well as radiofrequency ablation. Magnetic resonance imaging (MRI) of the lumbar spine indicates spinal malalignment with progressive multilevel degenerative disc disease, including multiple level disc herniations and stenoses. There is a request for Intracept procedure, which is an ablation of the basivertebral nerve.
The subject under review is whether the Intracept is going to be more beneficial to this patient than standard treatment.

The health plan's determination is upheld.

The proposed health service or treatment Intracept spinal procedure is not likely to be more beneficial than any standard treatment or treatments for the patient's condition. The patient has low back pain, and there is a request for radiofrequency ablation of the basivertebral nerve. Pathological involvement of the basivertebral nerve (BVN), an intraosseous vertebral nerve, may play a significant role in some forms of back pain. Although there are some studies available, in general, this procedure is not recommended until higher quality studies with longer follow-up periods are available, demonstrating long-term efficacy and possible adverse effects. Therefore, due to lack of sufficient evidence supporting this procedure, it is not likely to be more beneficial for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

The medical services rendered were appropriate but not medically necessary at the level at which they were provided.

The care provided did not require a full acute hospitalization. The patient could have received management of her pain at a lower level of care. 

Despite the patient's presentation the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection with mononucleosis; she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  The pain could have been managed at a lower level. As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations and lightheadedness
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

This patient presented complaining of palpitations and lightheadedness.  She was normotensive on examination, and electrocardiography did not reveal an etiology of palpitations.  The patient had a known history of such symptoms and was actively being treated for orthostatic hypotension.  This patient presented with lightheadedness and had an established diagnosis of orthostasis.  No significant cardiac findings were noted on serum blood testing or ECG. The patient had an inert implantable loop recorder that had previously not revealed any arrhythmic etiology for syncope, despite monitoring for a several year period.  The patient had the implantable loop recorder removed and was discharged the following day.  

According to the European Society of Cardiology, this patient was a low risk patient for future morbidity and mortality. (Reference 1) In a study of individuals presenting to the emergency room, patients that were low risk for cardiac events (no significant cardiac history of acute cardiac findings on initial evaluation) had an excellent prognosis and did not require admission to the hospital for further testing. (Reference 2).  

In this case, the patient falls into a low risk category, and she could have been managed a lower level of care. Therefore, the Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a petroclival meningioma, grade 2, post debulking.  Radiation therapy with stereotactic radiosurgery is recommended to decrease the risk of recurrence and progression.  A Ga-Dotatate positron emission tomography (PET) scan is requested to assist in radiosurgery treatment planning and delineation of tumor tissue versus normal tissue.  The health plan's determination is upheld.  There is a lack of significant studies published in peer reviewed United States (US) journals showing a significant benefit in the approach of treatment and side effects with this pretreatment scan.  There are case reports of potential benefit.  Additional larger randomized trials are needed to determine the efficacy and benefits of this imaging procedure for meningiomas.  This PET scan is not considered standard of care for this patient's diagnosis, and it is not supported by the oncologic medical community or the national societies as a standard of care for grade 2 meningiomas.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female diagnosed with idiopathic short stature (ISS).  This request is for Humatrope.  Her growth hormone (GH) stimulation test with clonidine and arginine peaked at 12.9 and 3.5 respectively.  Her pretreatment height velocity is reported to be 4.4 cm/yr. On 6/12/2019 her breasts are at tanner 3 and pubic hair is at tanner 2.  As reported, her mid-parental height was 165.25 cm (0.25 SDS).

The health plan's determination is upheld. 

Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society (1), the Lawson Wilkins Pediatric Endocrinology Society (2, 3), and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists(4).  The above referenced guidelines are the latest available guidelines from these respective societies.  The diagnosis is based on auxological, biochemical and sometimes radiological findings.  The auxological criteria based on consensus guidelines, upon which a biochemical evaluation is to be initiated are:  1) severe short stature, defined as a height more than 3 standard deviations (SD) below the mean; 2) height more than 1.5 SD below the midparental height; 3) height more than 2 SD below the mean and a height velocity over 1 yr. more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 yr. in children over 2 yrs. of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 yr. or more than 1.5 SD sustained over 2 yrs.  The biochemical criteria include low Insulin-like Growth Factor 1 (IGF1) or Insulin-like growth factor binding protein 3 (IGFBP3) or GH stimulation testing with a peak GH less than 10 nanograms/milliliter (ng/ml).

The patient did not meet biochemical criteria.  Growth hormone stimulation testing peaked at greater than 10.

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines (4-9).  Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height standard deviation score (SDS) less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."
The patient does not have a pretreatment height less than or equal to -2.25 SD.  The patient therefore does not meet idiopathic short stature criteria.

The request does not meet any nationally accepted criteria for use of growth hormone. The request is, therefore, not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pain, Decreased Endurance
 
Treatment: Increase in consumer directed personal care assistance services (CDPCAS) from 17 hours per week to an unspecified amount of hours per week.

The insurer denied the Increase in consumer directed personal care assistance services (CDPCAS) from 17 hours per week to an unspecified amount of hours per week. The denial was reversed.  

This is a male patient who has a history of hypertension, glaucoma, schizoaffective disorder, status post fracture, gait abnormality, nocturia, insomnia, dizziness, alcoholic liver disease, nicotine dependence, cocaine/cannabis dependence in remission. It was reported that due to the patient's pain, decreased endurance secondary to his comorbidities he required an increase in personal care assistance. He had been receiving 17 hours a week and was now requesting an increase to 28 hours a week. 
As per UAS, the patient needs assistance with multiple ADLs/IADLs.  The UAS-ATSP included an aide task plan for Monday-Friday; 16.76 total hours.  The number of CDPAS hours approved was 17 per week.  In the early 2019 UAS-ATSP Summary of Caregiver Info and Tasks, it was noted the patient lived with relatives who provided assistance with ADLs/IADLs (specific tasks and hours not noted).  However, in the insurer's final adverse determination letter it was noted that the patient lives alone and has no one who can provide assistance at home.  This is a significant change from the UAS, as the patient no longer receives assistance from informal caregivers at home.
Based on available information, it appears that the patient's medical conditions contribute in various ways to limit his ability to perform daily activities.  Regarding the patient's living situation, the most recent information available (insurer's final determination letter from mid-2019) indicates that the patient lives alone and has no informal caregivers to provide assistance (this is a change since early 2019 UAS).  Therefore, without informal caregiver support to provide daily care, an increase of personal care hours (in this case CDPAS) is medically necessary to provide the patient with assistance for IADLs and ADLs.  

As noted above, the patient's care needs could be better served with CDPAS 4 hours per day x 7 days per week; total of 28 hours per week.

The carrier's denial of an increase in consumer directed personal care assistance services (CDPCAS) from 17 hours per week to an unspecified amount of hours per week is reversed.  The medical necessity is substantiated.