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

The patient was admitted following medical screening to acute inpatient level services for monitoring, detoxification, and withdrawal management of severe alcohol, stimulant (Cocaine), cannabis (K2), sedative-hypnotic-anxiolytic (benzodiazepine), and opioid (Heroin) use disorders. He was using up to 10 bags daily of Heroin and 3 bags of cocaine with intravenous (IV) administration, one to three blunts of synthetic cannabis/K2 daily and 1-3 Xanax pills daily. The patient had experienced mild to moderately severe anxiolytic and opioid withdrawal at the time of admission with gastrointestinal upset, fatigue and restlessness. He had severe withdrawal symptoms in the past requiring detoxification services on at least two occasions. The substance use was occurring in the context of his participation in a Methadone maintenance treatment program with 60 mg daily of prescribed Methadone. The patient has a history of psychiatric disorders, treatment and hospitalizations with the diagnoses of bipolar mood disorder and posttraumatic stress disorder (PTSD); the most recent treatment was for a depressive episode with use of Seroquel, Zoloft and Neurontin. He was non-adherent with these medications and tended to stop his psychotropic medications when using substances of abuse. The patient was admitted to acute inpatient level care and placed on a detoxification regimen with Ativan and the continued use of the Methadone at his usual dose of 60 mg daily, together with vitamin replacement therapy, and medical monitoring. The health plan's determination of medical necessity is overturned. The presenting clinical features and history and risk for withdrawal seizures and other complications of anxiolytic and opioid and stimulant use disorders did warrant the admission and continued inpatient level services with medical monitoring in this case scenario. The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could not have been effectively provided at a lower level of care in this case scenario. 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 and effectively provided at a lower level of care. The adult inpatient treatment of this patient's substance use disorders and co-occurring psychiatric 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 in consideration of the associated psychosocial stressors and impairment of functioning.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
 
Treatment: Inpatient substance abuse rehabilitation

The insurer denied the coverage for inpatient substance abuse rehabilitation. The denial was reversed. 

This male patient was admitted to this inpatient substance treatment for substance rehabilitation. He was using 10-20 bags of heroin per day and had reports of intravenous (IV) use. He was also using 30 mg of amphetamines per day and 6 sticks of 2 mg Xanax per day. He had 10 prior substance treatments, including prior inpatient detoxification treatments in previous years. He had negative consequences due to substance use, including a prior driving under the influence (DUI) and drug related charges. He also had anxiety for which he was taking medication. He was unemployed. He lacked coping skills, needed to better identify relapse triggers and needed motivation for change and to build sober supports.  He was discharged with a referral to a clinic. 
He was considered at risk for severe and life-threatening complicated withdrawal and overdose due to the large amount of these substances being used. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he met criteria for inpatient substance rehabilitation treatment as he continued to use multiple substances despite treatment. He was unable to stop substance use without being in a sober and supervised therapeutic inpatient substance rehabilitation setting. Without this structured and supervised therapeutic treatment setting, he likely would have relapsed quickly.
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 of sepsis.  Following admission, there were no unstable vital signs reported.  He did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery.  He did not have bilateral obstruction, acute renal failure, or 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.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Schizophrenia
Treatment: Inpatient Mental Health Treatment

Summary: This patient was admitted to this inpatient mental health treatment in this hospital on due to psychotic symptoms including paranoid and Cotard delusions as he reportedly thought people were trying to kill him, and he thought he died and came back to life. He thought he was Jesus, did not feel safe, lacked insight, and was non-compliant with treatment .The patient had a reported diagnosis of Schizophrenia and reportedly had past psychiatric hospitalizations. He had treatment over objection for medication for Haldol and Risperidone. 

The insurer has denied coverage for the continued inpatient mental health treatment as not medically necessary. The denial was modified.
 
The American Psychiatric Association Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior, or inability to adequately care for basic needs are candidates for hospitalization. The denial was partially approved because the patient reportedly still had psychotic symptoms during the denial period including paranoid delusional thinking. Notes reported that he had treatment over objection for medication for Haldol and Risperidone as he had paranoid delusions and thought people were trying to kill him. He had multiple changes in his Haldol dosage to better target psychotic symptoms. Notes reported that he had delusions though less. It also reported that he was still resistive to taking medication but took it with encouragement from this hospital staff so he still required this 24 hour hospital treatment as he likely would have been non-compliant again and decompensated more if not in this hospital setting. Notes reported that he had delusions still and did not want to take some medication so he still needed hospital treatment until then. The subsequent days of the admission were denied because there were no further reports of delusional thinking or non-compliance, and he had no reported hallucinations, disorganized thinking or behavior, or psychotic symptoms. There were also no reports of severe agitation, severe depression, and there were no reports of suicidal or homicidal ideation. Notes reported that he had no delusions, no hallucinations, had linear thought process, normal speech, was co-operative, had neutral mood, and had no acute events. Notes reported that he was participating in group and providing insight. Notes reported that he had no delusions anymore and had improved affect.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: MRSA positive cellulitis
Treatment: Inpatient admission
The inpatient admission was medically necessary.
The patient meets the initial criteria for IV treatment and admission for cellulitis/abscess given by the Infectious Diseases Society of America (IDSA) (1), as he failed outpatient therapy and had systemic signs of infection (fever and tachycardia). There was a concern that he may have had a resistant bacteria (MRSA) with the history of such an infection and thus admission was warranted and standard of care. Thus, this admission was warranted, supported by IDSA guidelines, as well as standard of care. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Upheld

The patient was admitted to rehabilitation substance use disorder treatment of severe opioid and cannabis use disorders. Her use of these substances was causing significant risk to health and impairing her ability to function socially or occupationally. 

The health plan's determination is upheld. The Substance Abuse Residential Treatment Continued Stay 4/8/19 forward is not medically necessary for this patient. For the dates in question, the continued residential substance abuse rehabilitation treatment, in this case scenario, was amenable to treatment at a lower level of care. The patient was motivated and capable of effectively continuing in rehabilitation services in a less restrictive treatment setting with sober supports and/or housing.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bipolar disorder, Post traumatic stress disorder, substance abuse

Treatment: Residential inpatient substance abuse services 

The insurer denied inpatient substance residential treatment. That denial was reversed.

This patient was admitted to inpatient substance residential treatment due to opioid use. He also had other diagnoses reported including Bipolar Disorder and Post-traumatic Stress Disorder (PTSD). He was attending individual and group therapy and took Lithium, Remeron, and Clonidine, as well as Suboxone. He tested positive for codeine and morphine. He was still in this residential treatment at the time of the denial and was working on trying to get housing. 

This patient did not have the reported supports to be safely and effectively treated outside of this substance residential treatment. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that residential 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. Residential facilities provide a safe and substance-free environment in which residents learn individual and group living skills for preventing relapse. In this case, this patient was still considered in need of 24 hour residential treatment during the period in question, as it was reported that he met with the housing specialist the day prior. It was reported that he needed housing and he was considered to be in need of more structure in this 24 hour setting to work on triggers and coping skills. He had struggled to manage stress and family relationships which contributed to his use of substances. 

He was considered to be at risk for relapse, and outpatient substance treatment was not considered to be enough treatment at that time. He required continued inpatient substance residential treatment to give him the best opportunity to stop using substances and maintain abstinence, learn better coping skills and relapse prevention skills, and to better identify relapse triggers. He had comorbid psychiatric symptoms and diagnoses as well which put him at further risk as he was being treated with Lithium and Remeron for mood symptoms. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he met criteria for substance residential treatment as without this structured and supervised therapeutic residential treatment, he likely would have relapsed quickly.
Appeal type: Experimental/Investigational
Decision: Upheld

There was a handwritten note which noted that the patient complained of poor memory and focus.  There was a letter by the ordering physician appealing the denial of coverage for testing for MTHFR gene mutation and advanced lipoprotein testing.  He noted that the patient suffered from anxiety, depression, chronic pain, poor concentration, and poor memory.  He noted that the patient had a strong family history of dementia in both parents.  He noted that his opinion was that the requested tests were necessary.  

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes. For example, treating hyperhomocysteinemia had resulted in slowing progression of cognitive decline.  The patient has a memory complaint and first degree relatives with dementia. These tests might help give added information regarding her modifiable risk factors for dementia. Therefore, the scientific evidence in peer-reviewed literature does support a result of improvement in health outcome.

As noted in current peer literature, there is an international consensus statement that treating hyperhomocysteinemia is beneficial.

Per Licking N, Murchison C, et al. (2017), "We conclude that plasma homocysteine [HC] is significantly associated with some aspects of cognitive function in Parkinson's Disease [PD], and may represent a treatable risk factor for cognitive decline in PD."                                                    

This patient is a good candidate for CPT codes 81400 & 81401; and genetic test, CPT code 81291; date of service 6/30/18.  The patient has a memory complaint and first degree relatives with dementia and these tests might help give added information regarding her modifiable risk factors for dementia.  The testing is the best available treatment for this patient at this time as it can check for modifiable risk factors for dementia.   Additionally, it is likely to be more beneficial than any standard treatment/procedures for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

This case involves a female patient who underwent genetic testing for the MTHFR gene.  The patient also underwent testing for the advanced lipoprotein gene.  The documentation indicated that the patient has suffered from anxiety and depression, as well as chronic pain and fatigue, poor concentration and memory and cold intolerance for two to three years.  She does have a strong family history of dementia, as well as a personal history of fatty liver and hyperlipidemia.  The presence of the MTHFR gene mutation may explain methylation and detoxification problems.  The advanced lipoprotein testing was ordered because hyperlipidemia has been linked to developing dementia later in life.  

The general utility of testing lipoprotein has not been well delineated within the clinical setting and current guidelines do not recommend routine use of advanced lipoprotein tests, mainly because it is unclear how much prognostic information is provided by these tests beyond that which is available from a standard lipid panel.  In regard to the testing of the MTHFR gene, mutations in the MTHFR gene are associated with elevated levels of homocysteine in the blood, which has been suggested to elevate a patient's risk for cardiovascular disease. However, the value of measuring homocysteine levels is not clear, as a direct link of elevated homocysteine levels and cardiovascular disease has not yet been established.  Within the documentation, there is no indication that this patient has an extenuating circumstance that would warrant the need to certify the requested testing as literature does not recommend the specific testing.  The clinical utility and validity of the requested testing at this time is not proven in this clinical scenario.  Therefore, the scientific evidence and peer-reviewed literature does not support a result of health improvement for a patient in this clinical picture.  While the requested testing does have approval, it does not appear that the patient is an appropriate candidate.  Given all of the above, the requested service would not likely be more beneficial than any other standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Hyperlipidemia
 
Treatment: Blood test 

The insurer denied the lab tests, CPT code 81400 (Molecular pathology procedure, Level 1), CPT code 81401 (Molecular pathology procedure, Level 2); and genetic test, CPT code 81291 (MTHFR (5, 10-methylenetetrahydrofolate reductase) (e.g., hereditary hypercoagulability) gene analysis, common variants (e.g., 677T, 1298C). 

The denial was upheld as it was determined the testing was not likely to be more beneficial than any other standard testing.

This patient with a history of fatty liver, hyperlipidemia, anxiety and depression, chronic pain, fatigue, poor concentration and memory, and cold intolerance for the past two to three years.  There is a strong family history of dementia in both parents.  Per the blood test results MTHFR, DNA mutation testing were positive for two copies of the A1298c variant; APOE genotype was 3/3.

The tests (apoE and MTHFR) appear to have been ordered because of their association with Alzheimer's risk.  The ordering physician provides citations for articles linking variations in these genes to the risk of Alzheimer's disease.  MHTFR variation is also associated with depression.  However, these associations do not translate to clinical management.  These are tests used primarily in research.  In addition, it is not clear that the patient received genetic counseling prior to these tests.  These tests are not recommended by any practice guidelines.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. This patient is not a good candidate this testing. This is
not the best available treatment for this patient at this time, and the tests are not likely to be more beneficial for this patient than any standard treatments/procedures for this patient.
Appeal type: Medical necessity
Decision: Overturned

The patient was admitted to acute inpatient psychiatric services for an exacerbation of a chronic psychotic disorder best characterized as schizoaffective disorder, unspecified type. The patient had shown increasing symptoms of psychosis following discontinuation of  medication, Abilify, that included bizarre and erratic behavior, disorganized and delusional thoughts with paranoid thinking together with motor agitation and increasing responses to internal stimuli. The patient was refusing food and water. The patient was brought to the emergency department and was subsequently admitted after medical clearance that included physical examination, laboratory assessment and drug screen. The assessment included no abnormal or remarkable laboratory findings including a negative drug screen consistent with the history.

The patient was psychotic and cognitively impaired with thought blocking, laconic speech, grimacing with laughter, and response to internal stimuli. The patient was guarded and only superficially cooperative with poor eye contact. The patient displayed motor agitation with irritable mood. Insight was limited and judgment impaired. The patient denied suicidal ideation or aggressive impulses and did not show evidence for overt features of mania or severe cognitive impairment (delirium or dementia) despite having poor attention and concentration due to the internal stimuli and disorganized thought patterns with tangential thought production.

The patient's treatment plan included safety monitoring and medication targeting mood disturbance and psychosis, as well as the opportunity for therapy and psycho-education provided in the therapeutic milieu. The patient was uncooperative and consistently refused her scheduled medication. The patient continued to display severe symptoms of psychosis with essentially no change in the mental status examination, and continued refusal of food. The patient had a history of adverse reaction to Haldol and to Clozapine, so resumption of Abilify was ordered. The patient remained psychotic with continued evidence for affective instability, odd behavior, and responses to internal stimuli. The patient had bouts of motor agitation and uncontrollable screaming requiring frequent as needed (prn) medications and restraint with safety emergencies; the patient received intramuscular (IM) dosing of Thorazine and Ativan during these episodes.
The health plan's determination is overturned n whole.

The patient's continued hospital stay for treatment of an exacerbation of a psychotic and mood disorder (schizoaffective disorder) associated with non-adherence and non-compliance with outpatient treatment did warrant the continued stay through discharge.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizoaffective disorder
Treatment: Continued inpatient mental health treatment
The patient represented an acutely elevated risk of dangerous behaviors and there was no less-restrictive treatment environment appropriate.  The acute risk factors of psychosis with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of self-injurious behaviors (including but not limited to suicide) were he to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.  
The patient represented an elevated risk of dangerous behaviors including aggressive behaviors, self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore the treatment was medically necessary.  While the patient was not endorsing active homicidality, the patient remained psychotic and with suicidality.  The patient had multiple static risk factors for potentially dangerous behaviors including substance abuse, treatment non-compliance, and diagnosis with a severe mental illness.  Therefore the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained psychotic was an acute risk factor for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.