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

This is a patient who was admitted to inpatient rehabilitation substance use disorder treatment to address substance use disorder with stimulants (cocaine); alcohol; and opioids (heroin). The patient had no history of withdrawal seizures, delirium tremens or other episodes of severe withdrawal symptoms. He had a history of substance use disorder with multiple prior treatments with relapses though he had achieved a long period of sobriety in the past. He was using cocaine in large quantity with one half gram per day; and, daily use of alcohol with up to 9 beers and two pints of vodka; and, opioids with up to 5 bags of heroin with intranasal administration. His use of heroin was in spite of being in an outpatient treatment program with medication assisted treatment with Suboxone.
The health plan's determination is upheld.
The clinical features and indicated treatment dimensions of this patient's alcohol, stimulant and opioid use disorders, and co-occurring depressive disorder with associated symptoms of anxiety and post-acute withdrawal symptoms, did not require or warrant 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 multiple substances of abuse and ongoing outpatient treatment that included treatment for an unspecified depressive disorder. Moreover, the patient had been evaluated and cleared with regard to safety concerns, and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or general medical complications that would have warranted an inpatient level admission and treatment. The patient was engaged in treatment and motivated to participate in treatment, especially in view of the risk for re-incarceration and the support from his parole officer.
Thus, the requested inpatient level services were not medically necessary in this case scenario. Any indicated treatment for substance use disorder in this case could have been provided at a lower level of care, as clinically appropriate in keeping with American Society of Addiction Medicine (ASAM) Criteria and the NY State OASAS LOCATDR 3.0 Guidelines applicable in this case.
Appeal type: Medical necessity
Decision: Upheld

The patient has a past medical history significant for diet controlled hypertension who presented after having a syncopal event on the job.  The Patient felt weak and diaphoretic and passed and hit her head on a wooden dresser. 

The health plan's determination is upheld.  The inpatient stay was not medically necessary.  In this patient's case, no interventions occurred after leaving the ER that would warrant an inpatient admission.  The patient received no IV fluids but oral hydration only.  There was no documented serial neuro checks, or cardiac imaging.  Given no intervention occurred outside the emergency department, the inpatient admission was not indicated.
Appeal type: Medical necessity
Decision: Upheld

The patient has a past medical history significant for dementia, aphasia, urinary incontinence, gait abnormality and hypertension. The patient requests an increase in personal-care service assistant hours from 84 hours per week to 2/12 hour split shift services.

The health plan's determination is upheld. The Increase in Consumer-Directed Personal Care Assistance Services from 84 Hours per Week to Two (2) Twelve (12) Hour Split Shift Services is not medically necessary for this patient. Based upon review of information provided, there has not been any significant changes in the patient's medical condition noted in the patient's medical record which would account for an additional need for additional services.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Symptomatic gallstones
Treatment: Inpatient admission
The inpatient admission was not medically necessary. 

According to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), "patients undergoing uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis may be discharged home on the day of surgery" [SAGES]. Indeed, insofar as the patient did not demonstrate significant co-morbidities or physiologic derangements, and insofar as surgery and recovery were uncomplicated, the patient could have been treated at a lower level of care. 

Additionally, while intra-operative bleeding required electrocautery and hemostatic agents for control, by the end of the procedure, there was no further evidence of bleeding. Thus, intra-operative bleeding itself did not warrant admission at an acute inpatient level of care. 

Based on the provided medical documentation and in accordance with national guidelines, for this patient, admission at an acute inpatient level of care was not necessary. The patient could have been treated at an outpatient or observational level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
 
Treatment: Inpatient substance abuse services

The insurer denied coverage for further inpatient days. The denial was reversed.
This male was admitted to the inpatient substance detoxification treatment for detoxification treatment. It was reported that he had opioid withdrawal symptoms and was started on methadone for detoxification. He had methadone administered for five days, and was then transferred to substance residential treatment. It was reported that he was homeless and unemployed. He was discharged to inpatient substance rehabilitation treatment.
The reviewer disagrees with the decision to deny continuation of coverage for inpatient substance detoxification treatment. The patient had methadone detoxification treatment for five days to prevent severe opioid withdrawal.  In addition, he was homeless, lacked coping skills to maintain abstinence outside of a 24-hour setting, and he went directly from detoxification treatment to inpatient rehabilitation treatment. He required the five-day detoxification treatment prior to the substance rehabilitation treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol and Substance Abuse
Treatment: Inpatient stay
The inpatient stay was medically necessary for this patient.

The requested benefit of inpatient stay 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 cocaine that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. Detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient struggled with withdrawal symptoms in the context of co-occurring psychiatric disorders and with associated clinical features that included craving, limited insight, impaired judgment and poor control of impulses.

Thus, the admission and the continued adult inpatient stay and detoxification treatment of this patient's substance use disorders did necessitate an inpatient level setting with structure, supports, and 24-hour monitoring. The patient's history of substance abuse (frequency and quantity) together with the co-occurring psychiatric disorders (anxiety and depression), severe psychosocial stressors including probationary legal status 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 have been 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, 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 inpatient stay is clinically appropriate, medically necessary and warranted, and therefore should be covered 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. Thus, the requested benefit should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM Criteria and the application of NY State OASAS LOCADTR 3.0 Criteria, referenced below.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Dependence

Treatment:  Inpatient substance detoxification 

The insurer denied the Inpatient substance detoxification.  The denial was reversed. 

This is a middle aged female, who was admitted to a facility for alcohol and cocaine inpatient detoxification treatment in early 2019.  She had withdrawal symptoms including tremors, nausea, anxiety, irritable mood, lightheadedness, sleeping problems, teary eyes, and hypertension.  She reportedly had a positive toxicology for cocaine.  She had a history of depression and nervousness, inpatient substance detoxification treatment, a 25 year history of drinking and a 35 year history of using cocaine daily.  It was noted that she had hearing loss and was missing teeth.  She was started on Librium and Clonidine detoxification protocol.  She was discharged with a step down to inpatient substance rehabilitation treatment.

According to the LOCADTR she did require 24-hour treatment, as she could not safely and effectively be treated for detoxification in a less restrictive setting, as she continued to use large amounts of alcohol putting her at high risk of severe, complicated, or life threatening withdrawal.  Also, she needed detoxification medications including a 5-day Librium protocol to modify withdrawal from alcohol and also used Clonidine.  She needed 24-hour treatment, as she was at risk for worsened withdrawal symptoms if not in this 24-hour setting.  She was at risk for possible life threatening withdrawal such as delirium tremens, which can occur 3-4 days after cessation of alcohol use.  Also, she reportedly could not stop drinking large amounts of alcohol and using cocaine daily, despite past inpatient substance detoxification treatment.  It was also not likely that she could safely and effectively have outpatient substance detoxification treatment, as she could not stop use without being in a 24-hour sober setting.  She likely would have relapsed again, and she required detoxification treatment in this inpatient setting prior to inpatient substance rehabilitation treatment. 

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

The patient is a male with a history of hypertension, polysubstance abuse, and depression who presented with chest pain. At the time of presentation, the patient complained of palpitations diaphoresis and dizziness. He also has symptoms unrelated to the presentation of claudication. He was admitted to telemetry for cardiac monitoring.
Upon presentation, the patient had no hemodynamic compromise, abnormalities in cardiac enzymes and the electrocardiogram (ECG) was without significant findings.
During his stay, the patient was found to be bipolar with suicidal and homicidal ideation and needed psychiatric evaluation and 1:1 observation. The subject under review is the medical necessity of the inpatient stay. The health plan's determination is upheld.

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

The patient presented with a history of known coronary disease and atypical chest pain with no features concerning for an unstable coronary syndrome. He had no hemodynamic compromise, abnormalities in the clinical presentation or lab testing that placed the patient at high risk. There are no criteria as it relates to the chest pain presentation such as evidence of an acute coronary syndrome, abnormal heart rhythms, hemodynamic instability, or evidence of complications of an ischemic event such as heart failure.

Although the patient had known bipolar disorder with suicidal thoughts at the time of admission, there was no indication that an acute inpatient medical stay was warranted versus an a lower level of care status that would have allowed follow up cardiac testing to confirm no abnormalities in cardiac enzymes or ongoing symptoms, as well as psychiatric evaluation prior to discharge.
Appeal type: Medical necessity
Decision: Upheld

This patient presented to the Hospital with complaints of right-sided body and face numbness, unsteadiness, dizziness and blurred vision associated with headaches, nausea and photophobia. A head computed tomography (CT) scan and CT angiography performed on presentation were negative. Patient underwent a brain magnetic resonance imaging (MRI)  that was negative for acute ischemia or any other structural abnormality. An echocardiogram was negative for any embolic source. Her symptoms were improved, and she was discharged. Acute inpatient hospitalization was not medically necessary. This patient presented with headaches and focal neurological symptoms. Acute stroke required exclusion. Acute stroke could have been ruled out under a lower level of care using a brain MRI. Once acute stroke was ruled out and her headache pain was adequately treated, the patient could have been discharged. The patient otherwise did not require any neurological monitoring. The patient did not require any hemodynamic, cardiac or pulmonary monitoring. There was no need for intravenous medications or hydration. The HP determination is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of hyperlipidemia, hypertension and coronary artery disease. He presented to an urgent care/emergency department complaining of left shoulder pain with radiation to the neck and hand, headache, nausea, shortness of breath and diaphoresis. His blood pressure was 245/125 millimeters of mercury (mmHg). His serum troponin level was normal. He was treated with aspirin and nitroglycerin with improvement in his symptoms and his blood pressure. He was transferred to another facility for a cardiac catheterization.  The health plan's determination of medical necessity is upheld.
The patient was hemodynamically stable and pain-free. His cardiac catheterization showed no obstructive disease and the procedure was uncomplicated. Given his stable clinical status, normal biomarkers and lack of acute electrocardiographic changes, an inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient has a class I occlusion, moderate maxillary and mandibular crowding, moderate overbite and overjet. The proposed treatment is braces for 24-30 months. The subject to be determined is the medical necessity for braces. The health plan's determination is upheld, in whole. The requested treatment of braces (comprehensive orthodontic treatment) is not medically necessary for this patient. In this case the malocclusion is not considered handicapping in nature. The malocclusion in question does not meet the standard of care criteria to be classified as handicapping and treatment would not be considered medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 19 with no auto qualifier present. Using these evaluation methods, the malocclusion would require a score of 26 or more for treatment to be considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Continued inpatient detoxification 
The continued inpatient detoxification is medically necessary for this patient.

The adult inpatient detoxification treatment of this patient's substance use disorder did necessitate the continued structure of an inpatient level detoxification setting and monitoring. The patient's history of substance abuse together with severe psychosocial stressors and functional impairments reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure if 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, American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, and, with New York State instruction for medical necessity reviews including the application of the NY State OASAS LOCADTR 3.0 Guidelines (referenced below) that require the patient in this scenario default to the higher level of care.

The requested benefit of continued inpatient detoxification is medically necessary and is therefore a covered service in this case scenario. The patient could not have been reasonably provided an effective detoxification treatment in a less restrictive treatment setting in this case scenario or managed effectively with a lower level of care, as noted above. Thus, the requested benefit is not excluded under the plan, and should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM Criteria and the appropriate application of New York State OASAS LOCADTR 3.0 Criteria , referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol withdrawal
 
Treatment: Inpatient stay, medication, monitoring

The insurer denied the continued inpatient stay. The denial was upheld.

This female was admitted to inpatient substance detoxification treatment for alcohol detoxification treatment. She had withdrawal symptoms including tremors, blood pressure as high as 155/107, hot and cold sweats, anxiety, nausea, irritable mood, and difficulty sleeping. She reportedly was smoking 1-2 joints per week. She was put on a Librium protocol; last dose was 2 days prior to discharge. She was discharged to an inpatient substance rehabilitation treatment. 

The insurer denied coverage for continued inpatient substance detoxification treatment for the last 2 days of stay as not medically necessary treatment. She had no history of seizures or delirium, had no CIWA scores, did not require 24 hour detoxification treatment, and they recommended a less restrictive level of care.

According to the LOCADTR she did not require 24 hour treatment as she could safely and effectively be treated for detoxification in a less restrictive setting as of 1 day prior to discharge. There were no reports of withdrawal symptoms as of 1 day prior to discharge.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use
 
Treatment: Inpatient admission, medication management

The insurer denied continued inpatient stay. The denial was reversed.

This female was admitted to inpatient substance detoxification treatment for alcohol and opiate detoxification. She had withdrawal symptoms including tremors, nausea, vomiting, diarrhea, sleeping problems, joint pain, hot and cold sweats, irritable mood, and anxiety. She was reportedly using up to 7 bags of heroin per day and drinking 1 quart of alcohol daily. She had 5 past substance treatments including a recent inpatient substance detoxification treatment at start of the year. She had a positive toxicology for opiates and benzodiazepines. She had a history of past psychiatric hospitalizations and had depression and anxiety. She took Latuda and Prozac. She started detoxification medication for alcohol and opioid withdrawal. She took Librium and Methadone for the first 4 days of inpatient stay and was discharged to inpatient substance rehabilitation treatment on Day #5.

Patient could not safely and effectively be treated for detoxification in a less restrictive setting, and continued to use alcohol and heroin despite multiple past treatments. She needed 24 hour treatment as she was at risk for worsened withdrawal symptoms if not in this setting, including possible life threatening withdrawal such as delirium tremens. There was enough evidence to support that she required a 24 hour inpatient medical detoxification treatment until her discharge to an inpatient rehabilitation treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain
Treatment:  Inpatient admission
Inpatient level of care was not medically necessary.
This female patient with few risk factors for coronary artery disease (CAD), atypical pain for eight days, and no objective signs for ischemia was evaluated twice in that time period with no evidence found to support a diagnosis of heart disease.  After that period of symptoms, if there was significant ischemia, markers or electrocardiograms (EKGs) should be positive.  While the patient was admitted as a rule out ACS, she was never treated for the same.  She received analgesics, anti-anxiety agents, and medicine for GERD. 
Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care.  This is best reflected in the presentation, physical exam findings, and laboratory orders and their results, and highlighted in the orders for care. 
In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome.  Exam (BP normalized) and cardiac findings were normal.  Biomarkers and EKG showed no evidence of acute ischemia ("abnormal EKG" was borderline).  CXR was normal.  Echocardiogram showed no wall motion abnormality.  The physicians' treatment did not reflect any serious concern about the patient's cardiac condition.  Orders did not include medical therapy for ACS such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG).  She was discharged and was advised to see a cardiologist in the future. 
  The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care.  The only cardiac care provided was telemetry, frequently performed in a lower level of care.  The patient was admitted for monitoring and subsequent tests, and therapy did not require an inpatient level of care.  There was no complex care that required inpatient care.  This patient had no evidence of coronary artery disease (CAD).  All tests showed absence of ischemia.  While there is always a potential for an adverse event (and in this case a very low probability), one did not happen,, and no actual treatment was added.
Milliman criteria requirements were not fulfilled as there was never any evidence of ACS present.  To state that this was angina is inconsistent with the presentation, objective findings and treatment.  All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care.  Thus, inpatient level of care was not medically necessary.
This denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dizziness, vision changes, stuttering
Treatment:  Inpatient admission
The inpatient admission was medically necessary.
The patient had several risk factors for stroke, in addition to a fluctuating course during her hospitalization.  There is evidence that women who have migraine with aura are at increased risk of ischemic stroke, especially among those that are younger than age 45 years.  In addition, the patient has morbid obesity, transient increases in blood pressure during her admission and has Methylenetetrahydrofolate reductase (MTHFR) mutations, which can lead to a hypercoagulable state and increased the stroke risk.