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

Diagnosis:  Substance abuse
Treatment:  Continued inpatient detoxification 
The proposed treatment, continued inpatient detoxification, was medically necessary for this patient.

The continued inpatient detoxification 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 alcohol on a daily continuous basis together with crack cocaine that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring.  Detoxification, as indicated, 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.  Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms (tremor, sweats, headache, anxiety, irritability, restlessness and insomnia), which were being effectively addressed with Librium and supportive measures.  The patient had associated clinical features that included a depressive disorder with insomnia, and he presented with a lack of sober supports and limited insight, impaired judgment and poor control of impulses. 
Thus, the adult inpatient stay and continued detoxification treatment of this patient's substance use disorders did require the admission and the continued structure of an inpatient level setting with withdrawal management and psychosocial supports, and 24-hour monitoring.  The patient's history of substance abuse (frequency and quantity) together with the co-occurring depressive disorder and severe psychosocial stressors and functional impairments do 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 or general medical complications, such as seizures if detoxification and withdrawal management were to be attempted at a lower level of care.  Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, the American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, and New York State instruction for medical necessity reviews, including the appropriate application of NY OASAS LOCADTR 3.0 Criteria-referenced below.
The requested benefit of continued inpatient detoxification is clinically appropriate, medically necessary and warranted and is ,therefore, a covered benefit in this case scenario.  The admission and the continued inpatient level treatment through discharge could not have been safely or effectively provided with lower level services, as noted above.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse Dependence

Treatment: Inpatient Admission

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

This is a male patient who was admitted to this inpatient substance detoxification treatment in early 2019.  He reportedly had withdrawal symptoms including tremors, sweats, nausea, anxiety, irritable mood, cravings, and he had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 12.  He was drinking one gallon of alcohol per day.  He had a positive toxicology for benzodiazepines. He reportedly had abstinence for 10 months when in an inpatient substance rehabilitation treatment, but relapsed with alcohol and left against medical advice (AMA). He reportedly had legal issues related to drug and had been incarcerated for selling a controlled substance to an undercover police officer. He has a history of hypertension, and recent inpatient and outpatient substance detoxification treatment. He was put on a Librium protocol and completed the detoxification during this admission and was then discharged home.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports 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.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as he continued to use large amounts of alcohol daily, continued to use despite serious negative legal consequences and past inpatient substance detoxification treatment and past outpatient treatment, required and needed detoxification medication (Librium) to modify withdrawal and needed 24 hour treatment then as he was at risk for worsened severe, complicated, or life threatening withdrawal symptoms if not in this 24 hour setting then.  Also, he likely would have relapsed again as evidenced by relapsing after past treatments including after a 10 month inpatient rehabilitation treatment. 
    
The carrier's denial of coverage for the inpatient hospital services at the inpatient level of care is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse 
 
Treatment: Inpatient hospital substance detoxification treatment

The insurer denied the continuation of coverage. The denial was reversed. 
This male was admitted to this inpatient substance detoxification treatment in the
hospital for detoxification from alcohol and opiates.  He had a Clinical Opiate Withdrawal Scale (COWS) score of 15 and a Clinical Institute Withdrawal Assessment (CIWA) score of 12. Additionally, he had withdrawal symptoms including tremors, dilated pupils, restlessness, flushed face, elevated heart rate, nausea, and was irritable with an anxious mood. He had been using two to three bags of heroin and had prior use of non-prescription methadone. He was drinking two pints of vodka per day, and was smoking two blunts per day and had past crack/cocaine use up to three bags per day. He could not maintain abstinence. He also had hepatitis C. He had multiple past inpatient substance detoxification treatments in previous years. He was discharged to substance inpatient rehabilitation treatment.
He was at risk for severe, complicated and life-threatening withdrawal including delirium tremens which can occur four days after stopping use. As such, he required the entire detoxification treatment. He lacked coping skills and needed to improve identification of triggers and stressors contributing to use. In addition, he required this inpatient detoxification treatment prior to attending inpatient substance rehabilitation treatment to which he was discharged.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a listed diagnosis of chronic migraine. His headaches currently occur daily. The pain is bifrontal, behind the eyes, sometimes on the neck area, "pulling and pulsing", with photo and phonophobia, sometimes nausea. Aimovig 70MG/ML SC SOAJ is requested
The health plan's determination of medical necessity is upheld.
The patient suffers from daily headaches, which in the setting of use of several painkillers including Fioricet raises the possibility of medication overuse headaches, which should be considered and evaluated.
Furthermore, current guidelines and recommendations for the treatment of chronic migraines recommend the use of medications from three different classes; beta blockers, anticonvulsants and antidepressants. Such trials should last at least 6 weeks, although longer trials are frequently recommended, and at appropriate doses.
The trials listed for this patient have been, according to the documentation available, for one month, and therefore, cannot be considered a therapeutic failure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine fibroids and pelvic pain
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The medical records and peer-reviewed medical literature were thoroughly reviewed. The patient had an uncomplicated laparoscopic hysterectomy and was admitted postoperatively as an inpatient.  There is no evidence to support an inpatient admission based on her intraoperative and immediate postoperative conditions. 

A review of the physician progress notes and associated inpatient records does not reveal any evidence that the patient's postoperative condition required acute inpatient admission. The patient did not have co-morbidities indicating the need for an inpatient postoperative admission. There is no evidence of fever or abnormal vital signs, that her pain was uncontrolled, or that she did not tolerate oral (PO) intake overnight and through the first postoperative day.  It is not within the standard of care for a laparoscopic hysterectomy to be an ambulatory procedure with a same day discharge.  This patient required postoperative care; however, given her intraoperative condition and uncomplicated postoperative recovery, she could have been reliably discharged from the recovery room to a lesser level of care than an acute inpatient admission.  Therefore, the treatment was within the standard of care to be provided in a less than acute level of care setting, and not in an inpatient setting.  Therefore, the services were not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elective arthroscopic surgery of the right knee
 
Treatment: Inpatient hospitalization

The insurer denied the coverage of inpatient hospitalization. The denial was
upheld.
This is a female patient admitted to the hospital for elective arthroscopic surgery to her right knee.  She underwent a chondroplasty and lateral meniscectomy.  She received pain medication and Physical Therapy (PT) services after her procedure.  She was discharged. The medical record demonstrates the woman underwent a non-complicated procedure with limited morbidity.  It was of short duration with no blood loss. She was evaluated by a cardiologist, prior, who recommended use of a beta blocker.  This medication was provided without complication.  She was able to place full weight on the extremity.  PT services were provided on date of procedure.  She was able to tolerate oral pain medications.  She was able to tolerate diet. She did not require treatment for other underlying medical conditions.  
There were no extenuating circumstances to warrant the admission and length of stay.  This type of operation is typically completed in an Ambulatory Surgical Unit (ASU). The inpatient hospitalization was not considered medically necessary for this patient.
The carrier's denial of coverage for the inpatient hospitalization is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Amyotrophic lateral sclerosis (ALS).

Treatment: Provision of total care to patient 24 hours per day, 7 days per week by LPN.

The insurer has denied private duty nursing with an LPN 24 hours per day, 7 days per week. That denial was reversed.
This patient is a male with ALS. He is incontinent of bowel and bladder. He is a quadriplegic. He is bed-bound and non-communicative. He suffers from multiple advanced-stage decubiti ulcerations which require frequent dressing changes. He receives nutrition and medications via a PEG tube. He also requires turning every two hours, respiratory monitoring and oral suctioning. Around-the-clock nursing care is required for the patient to remain in the community. His high-acuity needs include: wound care (frequent dressing changes to prevent infection of sacral bedsores); mouth care (excessive secretions; patient does not allow suctioning so mouth is frequently cleared of secretions with swabs); aspiration precautions (excessive secretions obstruct ability to breath; occurs day and night; needs constant monitoring and intervention to prevent suffocation); feeding tube care (feedings, hydration, medication administration, flushing the tube; these tasks are needed multiple times per day); positioning/turning (for wound care, feeding, breathing); toileting (patient has 2 or more bowel movements per shift, day and night; requires diapering and wound dressing changes at any time day and night). His current caregiver can no longer function in this role; her role is now in a supervisory or emergency backup capacity.  
Due to the advanced stage of the patient's disease (ALS) and the occurrence of and high risk for complications, it is medically necessary for the patient to have skilled nursing services 24 hours per day to provide scheduled and unscheduled interventions and monitoring (including wound care, respiratory care, G-tube management, medication management). This includes 24 hour nursing (LPN) services.
Based on the above, the medical necessity for the private duty nursing with an LPN 24 hours per day, 7 days per week is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient has gastroesophageal reflux disease that is refractory to proton-pump inhibitor therapy. The patient has a complex gastrointestinal history, with Sjogren's disease and gastroparesis and has undergone esophagogastroduodenoscopy which demonstrated a normal esophagus without demonstrable hiatal hernia or esophagitis. In 2018, the patient underwent an esophagogastroduodenoscopy with pyloric dilation and botox injection for gastroparesis. Contrast radiographic swallow study demonstrated reflux to the level of the left ventricle. pH and manometry studies have been performed as well, with findings of increased esophageal acid exposure, normal lower esophageal sphincter pressure of 27mmHg and generally normal manometry. This review concerns whether the proposed transoral endoscopic procedure (Stretta) is indicated for this patient.

The health plan's determination is upheld. The proposed procedure is not likely to be more beneficial than standard treatments for this patient's condition. The procedure has not been studied in GERD patients with Sjogren's disease. While there may exist a reasonable impulse to seek a clinical intervention that is both more than PPI and medication therapy and less invasive than surgical fundoplication in this complex patient, it is also reasonable to acknowledge that the radiofrequency therapy is unproven. There may be significant unforeseen exacerbation of symptoms in a patient with Sjogren's disease. In sum, there is insufficient clinical evidence of efficacy, and no published data among patients with Sjogren's disease and gastroparesis. The requested procedure is not likely to be more beneficial than standard treatments for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

This patient has a history of symptoms of gastroesophageal reflux disease and laryngopharyngeal reflux. The patient also carries the diagnoses of postural orthostatic tachycardia syndrome (POTS), gastroparesis and Sjogren's disease. The patient has dysphagia and has tired proton pump inhibitor (PPI) medications in the past with significant nausea. The 3/20/19 history and physical (H&P) lists Prilosec among the medications. The patient also uses Gaviscon and has undergone dilatation and Botox injection of the Pylorus in 9/18 with some improvement in symptoms.

The health plan's determination is upheld. The requested procedure is not likely to be more beneficial than standard treatment for this patient's condition. The submitted clinical documentation does not establish that this treatment will yield the desired clinical result in this case for this patient with gastroparesis, dysphagia, POTS, and Sjogren's disease. The submitted clinical data includes surgical and gastroenterology notes, an esophagogastroduodenoscopy (EGD) report that shows describes treatment for gastroparesis, pH study, esophageal motility testing and an evaluation for gastroparesis with Smartpill. This patient carries the additional diagnoses of POTS and Sjogren's. In this case the proposed procedure is not known to be effective based on scientific evidence, professional standards and expert opinion in improving health outcomes.
Appeal type: Experimental/Investigational
Decision: Upheld

This patient has a history of long standing symptomatic gastroesophageal reflux disease (GERD). The patient has not improved with proton pump inhibitor (PPI) which was not tolerated secondary to nausea. The patient's past medical history (PMHx) is significant for Sjorgren's disease with dysphagia and gastroparesis which has failed medication.

The health plan's determination is overturned. The Heartburn Surgery: Transendoscopic Therapy is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Given that this patient may not be a candidate for surgical treatment of GERD, and unable to tolerate PPI, endoscopic treatment for GERD with the requested procedure is likely to be more beneficial than any other available treatment for GERD. Separately, as mentioned, the requested procedure is FDA approved for treatment of GERD and supported by the medical community with published guidelines within Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) as a standard non-surgical (endoscopic) treatment for GERD.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease
Treatment: Increase in PCA hours to seven days per week, eight hours per day, total 56 hours per week

The proposed treatment of an increase in PCA hours to seven days per week, eight hours per day, total 56 hours per week is deemed medically necessary. 

This patient is a female with a history of moderate to severe Alzheimer's disease. Due to her associated cognitive impairment, gait ataxia, urinary incontinence and failure to thrive; she requires assistance with the majority of her activities of daily living (ADLs). The currently approved schedule of personal care assistance, level II, six days per week, four hours per day for 24 total hour per week is insufficient to adequately cover all of this patient's needs including help with meal preparation, feeding, toileting, changing diapers, bed mobility and ambulation. For these reasons, the proposed treatment of an increase in PCA hours to seven days per week, eight hours per day, total 56 hours per week is deemed medically necessary to better assist with completion of the patient's ADLs.
Appeal type: Medical necessity
Decision: Upheld

The patient has multiple medical problems. The patient is currently receiving 5 hours a day times () 5 days week and 2 hours a day () 2 days a week for a total of 29 hours a week of personal care assistant service hours. The patient is requesting a total of 35 hours a week. The increase in personal care services is not medically necessary for this patient. The patient needs help preparing meals, housekeeping, laundry, shopping, dressing, bathing, toileting, medication management and personal hygiene.
The notes state that the patient is able to ambulate with a roller walker safely inside of the  house. Patient can use a shower with grab bar, is continent for bowel and bladder. The report states that the patient has occasional incontinence.  No health care aide time was noted to be necessary for this reason according to the Uniform Assessment System (UAS) state of New York. The patient uses a sanitary pad at night in case  is not able to make it to the bathroom on time.
Patient can transfer on own and there is no history of frequent falls.
Uniform Assessment System (UAS) state of New York noted that the patient required a total 19 hours a week of personal-care service hours. Most of the hours are noted in instrumental activities of daily living IADLs which include meal preparation and ordinary housework. Other areas of assistance, activities of daily living (ADLs) include bathing, dressing upper and lower body. There was no noted need for incontinence, toilet transfer, bed mobility or eating. There is no evidence that the patient has had a significant change in her ADLs which require additional services. Health plan determination is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sinusitis, deviated septum
 
Treatment: Functional Endoscopic Sinus Surgery

The insurer denied Functional Endoscopic Sinus Surgery. The denial was reversed.

This patient presented to the physician's office with complaints of nasal congestion.  The patient had been treated with antibiotics and steroid sprays, as well as allergy medication.  A Computerized Axial Tomography (CAT) scan of the sinuses raised the possibility of acute on chronic sinusitis.

The patient was evaluated by an otolaryngologist. The patient complained of severe congestion and swelling in the roof of his mouth for several weeks, pressure on his teeth, and nasal drainage.  The patient stated he had a root canal done last year and he felt his tooth was still hurting.  The patient's symptoms were improved with antibiotics, but returned once antibiotics were done. The patient complained of facial pain or pressure, nasal obstruction, and purulent drainage. The patient underwent a nasal endoscopy. The provider stated that the patient had been on three courses of antibiotics and had failed maximal medical management.  The septum was severely deviated and would need to be addressed.  There was not an odontogenic source. The request was made for endoscopic sinus surgery.  The patient then underwent a second evaluation. The recommendation was for a septoplasty and sinus surgery.  

The patient had subjective complaints and objective findings on physical exam, nasal endoscopy and CAT scan.  The patient had taken three courses of antibiotics with some improvement.  The patient had failed maximum medical therapy. 

Given all of the above, the requested Functional Endoscopic Sinus Surgery is considered medically necessary for this patient. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Discomfort in teeth #12, 13 and 18
 
Treatment: Porcelain crowns 

The insurer denied porcelain crowns. The denial was upheld.

This patient presented to her dentist for routine comprehensive dental treatment complaining of issues associated with teeth #12 and 13 which had full coverage crowns placed in 2016, and additional issues affecting #18.  The patient requested removal of crowns #12 and 13 which appears was completed, but the doctor declined the patient's other request and did not remove pre-existing crown #18. Replacement crowns as noted above for teeth #12 and 13 were then discussed.  

The objective documentation provided is peri-apical and bitewing radiographs and the dental chart clinical notes. It appears that there is no evidence of fracture or other pathology specifically affecting teeth #12, 13 or 18. There does not appear to be any radiographic evidence of caries.  There is no peri-apical pathology. Neither the radiographs nor the clinical notes substantiate the requested dental services as enumerated above, nor did the treating doctor indicate a need for replacement. The documentation is insufficient to justify or substantiate the requested treatment.

The carrier's denial of coverage for D2750 Crown - porcelain fused to high noble metal for tooth # 18, D2750 Crown - porcelain fused to high noble metal for tooth # 12 and D2750 Crown - porcelain fused to high noble metal for tooth # 13, should be upheld.