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

The patient presented to the emergency department with abdominal pain, nausea, vomiting and dark stool. On presentation, the patient had a temperature of 36.4, pulse rate of 86, blood pressure of 102/61, respiratory rate 17, and oxygen saturation 99% on room air. Bloodwork was notable for white blood cell (WBC) 6.27, hemoglobin 8.5, and hematocrit 27.7, platelet count 204,000, sodium 142, potassium 4.1, chloride 109, and bicarbonate 23, total bilirubin 0.7. The patient was admitted to the medical floor and treated with conservative management with intravenous fluid hydration, Protonix therapy and transfusion with 1 unit of packed red blood cells. Gastroenterology service consulted and esophagogastroduodenoscopy (EGD) was performed which revealed gastritis, hiatal hernia and one clean based duodenal ulcer. The patient did improve during the hospital course and ultimately was discharged with outpatient follow up.

The health plan's determination is upheld. The inpatient stay was not medically necessary. On presentation, the patient was hemodynamically stable without fever, tachycardia or hypotension. Bloodwork was notable for anemia without leucocytosis or significant electrolyte abnormalities. The patient was admitted to the medical floor and treated with conservative management with intravenous fluid hydration, Protonix therapy and transfusion with 1 unit of packed red blood cells. Gastroenterology service consulted and EGD was performed which revealed gastritis, hiatal hernia and one clean based duodenal ulcer. The patient remained hemodynamically stable throughout the hospital course and did not have ongoing active gastrointestinal bleeding. The patient did not require endoscopic intervention for bleeding or surgical intervention. The patient did not have end organ damage from severe anemia and therefore could have been safely and effectively cared for at a lower level of care. Based on the Milliman Care Guidelines (MCG), the patient did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post tooth fracture
 
Treatment: Post and Hard Material under Cap and the Tooth Colored Cap for Tooth # 5

The insurer denied the Post and Hard Material under Cap and the Tooth Colored Cap for Tooth # 5. The denial was upheld.    

This is a female patient who presented to the Dental Center for an emergent visit. The patient was status post tooth #5 crown fracture and crown one week prior to presentation. The patient had an x-ray that revealed one periapical (PA) was exposed and the tooth prognosis was questionable. The crown and post were cemented with Ketec and the site was cleaned for excess cement. The patient was discharged in stable condition.
A. G. B. Mentink et al. stated "Cast post and core restorations have a failure rate of 18% after 10 years. Nearly half of these failures are due to having the cast post and core and crown dislodge from the tooth, necessitating recementation". Morgano, S. M., & Milot, P. state: "The presence of a 1.5- to 2-mm ferrule has a positive effect on fracture resistance of endodontically treated teeth. If the clinical situation does not permit a circumferential ferrule, an incomplete ferrule is considered a better option than a complete lack of ferrule. Including a ferrule in preparation design could lead to more favorable fracture patters. Providing an adequate ferrule lowers the impact of the post and core system, luting agents, and the final restoration on tooth performance. In teeth with no coronal structure, in order to provide a ferrule, orthodontic extrusion should be considered rather than surgical crown lengthening. If neither of the alternative methods for providing a ferrule can be performed, available evidence suggests that a poor clinical outcome is very likely. Repetitive dislodgement of a cast post and core is often indicative of root fracture, requiring tooth extraction as the best treatment."

With all of these factors in mind, the evidence strongly indicates that this tooth has a poor prognosis. Therefore, the healthcare plan acted reasonably, and with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the post and hard material under cap and the tooth colored cap for tooth # 5 is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Other (vomiting/dehydration)
Inpatient stay

12 hours prior to the current admission, the patient presented to the emergency room (ER) for multiple episodes of vomiting after feeding, diarrhea, fever and cough. Fever was abated in the ER, cough persistence decreased, and the patient was discharged after a successful oral food challenge. The patient returned with recurrent symptoms. Exam at presentation to the ER revealed decreased activity, fatigued and patient appeared dehydrated. Patient also had dry oral mucosa. Assessment was viral syndrome with fluid losses > than compensation given the lack of fluid repletion at home. This patient was with an inability to tolerate oral intake with continual diarrhea. Patient  was found to have a low bicarbonate level of 15 and slightly increased ion gap at 13. Patient was admitted for IV hydration. The health plan determination is overturned in whole.The inpatient hospital stay was medically necessary for this patient. This patient presented not only with physical findings but also laboratory evidence of significant dehydration associated with electrolyte aberration. Also evident was metabolic acidosis. Apart from this, the patient had poor PO intake with frequent episodes of diarrheal stools and continued vomiting. This patient would require IV hydration to compensate for his GI losses that the patient was unable to match orally. Based on current criteria, this patient was a candidate for admission due to his inability to maintain oral hydration, and Per the literature current criteria for admission were met.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hematuria
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient's care could have been provided at a lower level of care.  He was afebrile and hemodynamically stable throughout the hospitalization. There was no evidence for sepsis.  Following admission, there were no unstable vital signs reported.  He did not have infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have acute renal failure.  Pain control, IVF and a urology consult in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible amaurosis fugax
 
Treatment: Inpatient admission, diagnostic testing, monitoring

The insurer denied the inpatient admission. The denial was upheld.

This is a male who presented to the emergency department with a complaint of 3 episodes of vision changes since the day prior to evaluation.  The episodes lasted about 3 minutes with each eye becoming blurry, but they resolved.  The patient noted he felt unwell x1 month. He reported he woke up with night sweats.  He was alert and oriented and had no deficits on neurologic checks; there was no facial droop or drift of extremities, and his pupils were equal and reactive to light.  The patient's past medical history included attention deficit hyperactivity disorder, testosterone replacement, drug use, and hypertension.  The patient admitted to taking muscle-building supplements.  Blood pressure was 141/66, heart rate was 95, and respiratory rate was 18.  The EKG revealed normal sinus rhythm.  He reportedly was using cocaine on the "weekends". The patient was admitted to the stroke unit for possible amaurosis fugax. He underwent diagnostic testing and neurology and cardiology consultations. He was later discharged.

MCG notes that an admission is appropriate for a patient with a transient ischemic attack when the patient has focal neurological signs or symptoms that persist or recur, or for a cardiac arrhythmia of immediate concern or hemodynamic instability. The records failed to support the patient had a transient ischemic attack with focal neurologic signs or symptoms that persisted or recurred.  The patient was not noted to have a cardiac arrhythmia of immediate concern or hemodynamic instability. The patient could have undergone the consultations and diagnostic testing at an observation level of care.  The patient was appropriate for observation.  

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Atrial fibrillation; back pain
Treatment: Transcatheter closure of the left appendage
The health plan should cover the proposed treatment.

The requested health service or procedure is likely to be more beneficial than any standard treatment(s) for the patient's condition or disease.  

This patient had an elevated CHADSVASC score, indicating that he has a significant risk of stroke following a diagnosis of atrial fibrillation (AF). To reduce the risk of stroke, oral anticoagulant medications were appropriately prescribed.  However, these medications interacted with the patient's non-steroidal anti-inflammatory medication (NSAIDs) that was critical for chronic debilitating back pain.  The patient consulted with a pain management specialist in search of alternative efficacious medications.  Despite these efforts, he noted worsening pain and decreased ability to ambulate and function.  Oral anticoagulant medications and NSAIDs cannot be administered concomitantly on a long term basis due to the risk of gastrointestinal bleeding. A substudy of the RELY trial (randomizing patients to Pradaxa versus Warfarin for stroke prevention in patients with AF) revealed that patients taking oral anticoagulant medication with NSAIDs had a significant risk of gastrointestinal bleeding. (Reference 1).  

Left atrial appendage occlusion has been shown to be non-inferior to warfarin therapy in preventing stroke in patients with atrial fibrillation. (References 2-5)  Current guidelines recommend considering transcatheter left atrial appendage occlusion in patients that suffer from atrial fibrillation, have an elevated risk of stroke, and a contraindication to oral anticoagulant therapy due to an elevated risk of bleeding. (Reference 6)  Current FDA guidelines approve the use of the Watchman device in patients that have an elevated risk of stroke based on the CHADSVASC score and have appropriate rationale to seek an alternative to long term anticoagulant therapy.  This patient has a CHADSVASC score of three and a HASBLED score of three - clearly meeting these criteria.  In conclusion, transcatheter left atrial appendage occlusion is more beneficial than any other treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Atrial fibrillation; back pain
Treatment: Transcatheter closure of the left appendage
The health plan should cover the transcatheter closure of the left atrial appendage.

The requested health service or procedure is likely to be more beneficial than any standard treatment(s) for the patient's condition or disease.

The patient has a documented history of atrial fibrillation, and an elevated CHADS-VASC score, and it would be consistent with the current guidelines that chronic anticoagulation be used for reduction of his risk of thromboembolic complications, such as CVA. The Watchman left appendage closure device is FDA approved and is currently considered to be an appropriate therapy for patients in whom the use of long-term anticoagulation is not an option, which would be consistent with the medical history in this case. Therefore the use of the requested device would be considered to be medically appropriate in this clinical setting. Therefore the requested procedure is likely to be more beneficial than any standard treatment or treatments for the insured's condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Atrial fibrillation; back pain
Treatment: Transcatheter closure of the left appendage
The health plan should cover the transcatheter closure of the left atrial appendage.

The requested health service or procedure is likely to be more beneficial than any standard treatment(s) for the patient's condition or disease.

The Watchman device, a percutaneous closure of the atrial appendage, is an approved device which is becoming more common in its use. While the original indication was limited to patients with absolute contraindications for anticoagulation, its use has been liberalized throughout the cardiology community. The United States Food and Drug Administration approval has become more liberal and now includes new guidelines for patients eligible for oral anticoagulation; and has other indications for non-pharmacologic therapy (e.g., lifestyle indications, labile international normalized ratio). This patient falls into this new category, patients who require the device for reasons outside just an inability to take any anticoagulation. The patient's treating physician stated that NSAIDs are the only viable treatment for the patient's pain; and long term use of high dose NSAIDs in a patient on anticoagulants is inadvisable; it is appropriate to place this device.  Appropriate utilization guidelines for this device are constantly being updated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major depression and bipolar disorder
 
Treatment: Inpatient mental health admission

The insurer denied the inpatient mental health admission. The denial was reversed.

This female was admitted to inpatient mental health treatment due to severe and worsened depressive symptoms interfering with her ability to care for her basic needs.  She reportedly had dysphoric mood and suicidal thoughts.  She had reports of crying, psychomotor retardation, cognitive slowing, poor concentration, increased sleep, feelings of guilt, ruminating, decreased eating including only drinking Gatorade, not showering in 112 weeks, not shopping, and not taking care of herself.  The patient had a diagnosis of Bipolar Disorder in addition to this current major depressive episode.  She had two past reported psychiatric hospitalizations.

The medical records provide enough specific evidence to support that she required 24 hour psychiatric hospital treatment.  The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and also that patients with severe agitation, aggression, psychotic symptoms, suicidal or homicidal plan or intent or attempts, manic episodes, severe major depressive episodes, or inability to adequately care for basic self-care needs are in need of hospital treatment.  

The patient was unable to adequately care for her basic needs until discharge, so she still required inpatient hospital treatment.  The recommendation is to reverse the previous decision and approve coverage for inpatient mental health treatment.

The carrier's denial of coverage for the inpatient hospital admission is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Substance Abuse
 
Treatment: Continued Inpatient Detoxification Level of Care

The insurer denied the Continued Inpatient Detoxification Level of Care.  The denial was modified.      
This is a male patient who presented to a rehabilitation facility for detoxification treatment. The patient tested positive for opiates, cocaine, and tetrahydrocannabinol. His presenting symptoms included joint discomfort, restlessness, elevated heart rate, anxiety, and irritability. He admits to using intravenous (IV) heroin, tens of dollars' worth of crack, and smoking 2 blunts of cannabis daily. He has a history of Naltrexone use and it was reported that he relapsed after he stopped taking it. He had a history of depression, anxiety, including an attempted suicide, and inpatient substance detoxification and rehabilitation treatment. He was placed on a methadone protocol. The patient signed out of the facility against medical advice (AMA). 
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that patients with comorbid medical conditions complicating withdrawal, acute medical instability, or a reported history of complicated withdrawal symptoms such as delirium tremens or withdrawal seizures are in need of inpatient substance detoxification. It also states that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. 

The patient was in the facility for a total of 11 days. The first four days were approved by the insurer. After this review, one additional day was approved. All subsequent days were denied.

According to the LOCADTR he did require 24 hour treatment for the first five days as he needed detoxification medication to modify withdrawal and had a history of daily IV heroin use, which put him at high risk for overdose. He needed 24 hour treatment due to this risk, and he had past inpatient substance treatments and continued to use heroin and crack. Therefore, outpatient treatment for detoxification was not considered enough or safe as he needed 24 hour treatment for detoxification. However, as of the sixth day there were no further reports in the medical records provided stating that he still had withdrawal symptoms or that he still was in need of Methadone detoxification. 

The insurer's denial is modified. Based on the above, the medical necessity for the continued inpatient detoxification level of care for the first 5 days is substantiated. Inpatient detoxification level of care from the sixth day until the day the patient signed out AMA is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance abuse
Treatment:  Continued inpatient admission 

The continued inpatient admission was medically necessary for this patient.

The requested benefit of the continued inpatient admission 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 opioid/heroin together with near-daily use of a benzodiazepine anxiolytic (Xanax) and intermittent use of cocaine that did warrant 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 presented with moderately severe withdrawal symptoms, and the patient's social environment was not conducive to detoxification, and the patient struggled with withdrawal symptoms up until the time interval under review in the context of limited insight, impaired judgment and poor control of impulses.

Thus, the continued detoxification treatment of this patient's substance use disorder did necessitate the continued structure of an inpatient level detoxification setting and monitoring.  The patients history of substance abuse (frequency and quantity), and 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 the continued detoxification and withdrawal management were to have been continued 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 LOCADTR Tool that requires the patient in this scenario default to the higher level of care.

The requested benefit of continued inpatient admission is medically necessary in this case scenario and should, therefore, be a covered service in this case scenario.  The patient's clinical features and treatment dimensions did warrant continued inpatient level detoxification services through discharge and did necessitate the monitoring that is provided with inpatient level treatment including the use of comfort medications and seizure precautions.  Moreover, the continued substance abuse detoxification 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 New York State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Continued inpatient admission

The continued inpatient admission was medical necessary for this patient.

The continued inpatient admission and treatment 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 heroin, non-prescribed Suboxone and methamphetamine together with large quantity of other substances including alcohol, Xanax and cannabis that did warrant 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 had persistent withdrawal symptoms, and the patient's social environment was not conducive to detoxification. The patient struggled with withdrawal symptoms during the time interval under review in the context of limited insight, impaired judgment and poor control of impulses.

Thus, the adult inpatient detoxification treatment and withdrawal management of this patient's substance use disorder did warrant the admission and the continued structure of an inpatient level detoxification setting with 24-hour monitoring and use of prn medications. The patient's history of substance abuse (frequency and quantity) together with the drug-infested social environment, and 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 the continued 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 the NY State OASAS LOCADTR Tool that requires the patient in this scenario default to the higher level of care.