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

Diagnosis: Post Traumatic Stress Disorder (PTSD); Generalized Anxiety Disorder; Borderline Personality Traits

Treatment: Residential mental health treatment

The insurer denied for Residential mental health treatment. The denial was upheld.

The patient is a female admitted for residential mental health treatment.  She was diagnosed with Post Traumatic Stress Disorder (PTSD), Generalized Anxiety Disorder, and Borderline Personality Traits on initial psychiatric evaluation.  At the time of her admission she was on Abilify and Seroquel PRN for sleep/anxiety.  Residential Notes, Group Notes, Family Therapy Notes, and Individual Therapy Notes provide little to no clinical information; rather they reference the patient's chronic behaviors and symptoms and report that she needs to continue to focus on these issues in her therapy.  Psychiatric notes indicate various medications that were prescribed to deal with anxiety, insomnia and medication side effects.  There is no indication that the patient was having severe depression, anxiety or psychosis.  There was no indication that she was acutely at risk of harm or herself or others.   A Treatment Team Note indicates the patient is on Abilify, Seroquel, Cogentin, Trazodone and Gabapentin.  She has shown significant gains in all of her treatments and displayed genuine and authentic growth in feelings of self-esteem and self-worth.  She was doing a great job as kitchen manager and was a leader in the community.

Based upon the information available the patient did not medically require residential mental health treatment substance abuse detoxification. There is no medical documentation indicating the patient's need for 24 hour per day monitoring in a residential setting.  There was no indication of severe acting out behavior, psychosis, severe depression, or severe impulsivity.  She had received over two months of residential treatment and made appropriate use of such treatment.  She could have transitioned to a lower level of care.

The carrier's denial of coverage for 74 units of residential mental health treatment is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Adeno-tonsillectomy
 
Treatment: Inpatient admission

The insurer denied the Inpatient admission. The denial was upheld. 
This is a female child who was seen in early 2019 for consultation for sleep disturbance.  The patient had history of snoring for years.  She had poor, restless sleep with arousal.  Polysomnogram was ordered, by the primary medical doctor, which was abnormal.  Large tonsils were noted.  She has had 3-4 positive strep cases over her lifetime.  Eating and swallowing were okay.  The patient sounds hyponasal and is congested often.  The patient gets recurrent random nosebleeds.  On examination, the tonsils were noted to be grade 2-3+.  The uvula was midline and normal.  Tongue and palate were normal.  The sleep study revealed moderate sleep apnea.  Oxygen desaturation was 91%.  The patient underwent an elective adenotonsillectomy in early 2019 to improve sleep and breathing.   She was then admitted after the procedure.  The patient was given IV fluids and pain medications.  Her diet was then advanced and she was discharged the next day.
The medical literature indicates that inpatient admission may be indicated for pediatric patients if there is evidence of hemodynamic instability, hypertension, cardiac arrhythmias of immediate concern, severe heart failure, respiratory, neurologic or abdominal abnormalities, reduced urine output, acute renal failure, significant uremic complications, high fever or other high risk infection, severe electrolyte or metabolic abnormality, acute blood loss causing significant abnormality or severe pain requiring inpatient management. 
There was no indication that the patient had any complications following this procedure.  The documentation indicated that the patient was to stay overnight due to sleep apnea and the distance of the parents.
The insurer's denial of coverage for the inpatient hospital services for admission should be upheld. Medical necessity was not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance abuse
Treatment:  Inpatient residential treatment
The proposed health service of inpatient residential treatment was medically necessary for this patient.

The admission and continued inpatient residential level of services, structure, and monitoring provided in this case are warranted in view of the severity of the alcohol use disorder and associated symptoms of co-morbid depression and anxiety, as well as the psychosocial stressors and functional impairments in this case scenario.  The patient could not have been safely or effectively managed with lower level services during the time interval under review, especially in view of the safety concerns and severity of psychopathology in this patient.  The inpatient residential level services that included intensive rehabilitation treatment and treatment for the mental disorders with medication and therapy (CBT & ERP) were clinically appropriate and consistent with prevailing standards of medical practice.  The services were provided with evidence-based treatment that are known to benefit patients with severe alcohol use disorder and co-occurring mood and anxiety disorders, as well as providing services to address treatment issues in a patient with severe psychosocial stressors and high risk for relapse or suicidal behavior.  Thus, the patient's severity of alcohol use disorder and associated symptoms of depressive disorder and anxiety disorder and other symptoms related to persistent craving and/or PAWS did warrant and necessitate the admission and the continued inpatient residential level services, as proposed, with the plan for step down to lower level services once the patient had stabilized with work on a relapse prevention plan and improved coping skills and the ability to achieve abstinence with sober supports in working toward discharge with the support of his family. 

Moreover, the patient presented with high risk for relapse in view of an inadequate recovery environment, a relative lack of coping skills, and readiness to change that was being addressed with motivational techniques.  Indeed, the additional time spent with motivational techniques and developing a solid step down were essential to a successful therapeutic outcome in this case, including family focused sessions to improve or enhance sober supports.  Again, the psychosocial stressors in this case were substantial in the context of acute symptoms of depression and anxiety and family conflicts that were significant triggers to use alcohol and cannabis.  These clinical features and treatment dimensions did support the necessity for the inpatient residential level services and the continued structure and monitoring and intensity of services provided at the inpatient residential level of care, as requested, through step down to lower level of care treatment..
Appeal type: Medical necessity
Decision: Overturned

This is a patient who was admitted to inpatient level care following medical screening, for monitoring and detoxification and withdrawal management of severe alcohol, stimulant (cocaine), and cannabis use disorders. He was consuming large amounts of alcohol per day with up to one-half pint of vodka and two 24 ounce beers, and one half gram of crack cocaine, and one blunt of marijuana daily.  The health plan's determination of medical necessity is overturned.
The adult inpatient treatment of this patient's substance use 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 the associated psychosocial stressors and impairment of functioning. Withdrawal symptoms were managed with tapering dosages of benzodiazepines requiring monitoring and as needed (PRN) medications, as well as the availability of comfort medications and nicotine replacement and vitamin replacement therapy to prevent the onset of encephalopathy.
Appeal type: Medical necessity
Decision: Upheld

The patient had a history of multiple substance use disorders (alcohol, sedatives, opioids) who received medically supervised withdrawal services. The patient had last use heroin, alcohol, and benzodiazepines. The patient was reported to have been using 8 milligrams (mg) daily of an unknown benzodiazepine though documentation indicates that the patient used only one to three times in the last 30 days. The patient used alcohol also one to three times in the prior 30 days. The patient had a history of a rehabilitation admission. The patient had been on methadone maintenance prior to admission. Inpatient detoxification services level of care is under review.

The health plan's determination is upheld. The Inpatient Detoxification Services is not medically necessary for this patient.There had been no changes that necessitated a higher level of care. The withdrawal symptoms did not continue to require a 24 hour medical oversight in a hospital setting due to serious and life-threatening complications. The withdrawal did not continue to require medical supervision, stabilization, and regular vital sign monitoring.
The clinical documentation does not establish that the patient needed inpatient care for the dates in question. The patient was not having severe withdrawal symptoms by this time. It appears the patient may have been kept waiting for an available bed in a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient presented for inpatient detoxification treatment in order to address severe substance use disorder with opioid (heroin) and stimulant (crack cocaine) class substances of abuse. The patient also has chronic lower back pain that resulted from an injury due to a gunshot wound. The patient reported a past history of severe withdrawal symptoms when attempting to curtail use, and had recently undergone a detoxification treatment approximately two months prior to presentation with relapse and resumption of use of heroin and crack cocaine The patient had only recently used cocaine, but had been using heroin since the age of 17 years with longstanding use and only the one prior treatment episode. The patient was using up to 9 bags of heroin and 1 gram of crack cocaine on a daily continuous basis. The health plan's determination is overturned.

The continued inpatient treatment of this patient's substance use disorder with detoxification and withdrawal management did require the continued structure of an inpatient level setting and 24-hour monitoring in view of the patient's clinical presentation and course of treatment and risk factors for relapse and lack of a reasonable treatment/recovery environment. Withdrawal symptoms were appropriately managed with tapering dosages of methadone requiring monitoring and supportive measures including the availability of nicotine replacement therapy and comfort medications, as noted in the clinical summary. The patient's history of opioid use and recent use of crack cocaine, limited psychosocial supports and psychosocial stressors within several domains including limited social supports, and risk for relapse in view of recent detoxification with relapse did reflect the seriousness of the substance use disorder and a complicated case with regard to the ongoing struggle with chronic pain and addiction to multiple substances of abuse.
Thus, the patient did require a safe and effective detoxification treatment for the dates in question as it was foreseeable that the patient was unable to abstain from use of opioid or cocaine, or maintain abstinence if detoxification were to be attempted at a lower level of care. Moreover, the continued inpatient level care through discharge was warranted using the NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria.
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 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 together with large quantity of alcohol on a daily continuous basis; and use of other substances of abuse (cannabis and tobacco) that did warrant 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 detoxification, and the patient had struggled with withdrawal symptoms and craving which did require the continued withdrawal management and monitoring in an inpatient setting in the context of limited insight, impaired judgment and poor control of impulses in view of his treatment history and clinical features of substance use disorder.

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 and the continued tapering of Librium and methadone per the detoxification protocol. 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. 

Indeed, the patient's clinical features and treatment dimensions did warrant inpatient level detoxification services through discharge and did necessitate the monitoring that is provided with inpatient level treatment, including the use of comfort medications, together with counseling and educational sessions and peer support. Case management services were critical in this case to motivate the patient to proceed to rehabilitation treatment and formal substance use disorder treatment with a safe and clinically appropriate disposition with sober housing. Moreover, the admission and the continued substance abuse detoxification 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: Malocclusion and crossbite
 
Treatment: Orthodontic care

The insurer denied the orthodontic care. The denial was reversed.

This patient presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to Class III malocclusion, anterior crossbite with gingival attachment loss (mandibular incisor) transposed canine and lateral incisor, and mild maxillary and mandibular crowding.  The orthodontist has completed the Handicapping Labiolingual Deviation (HLD) index as required.  The insurer denied coverage for orthodontic treatment as not medically necessary. 

It is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized.   

The treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. The clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labiolingual Deviation Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

Braces (comprehensive orthodontic treatment) are considered medically necessary for this patient.  The carrier's denial of coverage for braces (comprehensive orthodontic treatment) is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Malocclusion and crossbite
 
Treatment:  Orthodontic Care
The insurer denied the orthodontic care.  The denial was upheld.

This patient presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics, due to Class I malocclusion, Class II canines, deep bite, anterior crossbite with gingival attachment loss and mild maxillary and mandibular crowding. 

It is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and, therefore, medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.   Additional criteria are used utilizing a point system, if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.  In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  This automatically qualifying condition criterion is not met to support comprehensive orthodontic care.  The clinical circumstance does not meet criteria to justify orthodontic care.  The reviewer concurs with the insurer attaining a score of 13 points on the HLD index, which is below the threshold of 26 points to justify orthodontic care.

Handicapping Labiolingual Index has been shown through scientific scrutiny in peer reviewed journals to be a valid approach for assessing orthodontic need.   

Based on the above, the medical necessity for Comprehensive Orthodontic Treatment of the Adolescent Dentition (D8080) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mood Disorder, Complex Posttraumatic Stress Disorder (PTSD), and Anxiety Disorder
 
Treatment: Inpatient Admission

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

The is a female patient admitted to the Hospital for acute inpatient psychiatric treatment after spending 48 hours or more in the Emergency Room awaiting bed placement.  She presented with obsessive suicidal thoughts of jumping from the roof of her parent's apartment building (she was residing with her parents).  She has had a long history including childhood trauma, depression and anxiety and has had many previous hospitalizations for suicidal ideation and self-harming acts, benzodiazepine dependence, two medication overdoses, most recently in mid-2017.  She had been hospitalized several weeks earlier for suicidal ideation and had been attending a partial hospital program (PHP) at the time of admission. She indicated on admission that she had been researching ways to commit suicide. Upon admission she was on sertraline, olanzapine, gabapentin, hydroxyzine and trazodone.  She required a dose of olanzapine at the time of her psychiatric evaluation due to feeling panicked, terrified and trapped.  The medical record noted that she continued to be described as severely dysphoric and anxious and having ongoing ego-dystonic thoughts of suicide and dying.  She was treated with clonidine and lithium, in addition to her other medications, and she was assessed for electroconvulsive therapy (ECT) treatment which she rejected. Disposition planning for extended hospital care took place at the beginning of her treatment, including a transfer to another treatment facility. As hospital stay progressed she was less anxious and labile compared to admission, and she continued with chronic suicidal ideation, but no acute plans or intents.  Her anxiety and agitation continues to show a decrease, but had ongoing intermittent periods of being overwhelmed.  Attempts to have her return to PHP were made, but the program had no openings. She was discharged after being accepted to a treatment facility.  

The patient medically required acute inpatient psychiatric treatment. The patient had a history of severe impulsive and dangerous behavior.  She was admitted with a plan to throw herself from a building in a suicide attempt.  Her mood was poorly regulated.  Although the act of her being in a hospital provided structure and lowered her imminent risk of harm while hospitalized, that lowered risk would only continue if she were in highly structured ongoing treatment.  Such treatment was not able to be arranged despite appropriate efforts to do so on the part of her clinical team.  As such, she continued to require acute inpatient psychiatric treatment until such alternative treatment was arranged upon discharge. 

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

Diagnosis: Dizziness and weakness
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient presented to the ER for further evaluation/management of dizziness and weakness. Her intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. Her examination was non focal with no significant abnormalities noted, including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen. Her laboratory and ECG testing were also within normal limits with no significant abnormalities noted, including no evidence of acute end organ damage. The medical records indicate that this patient was admitted to the inpatient medical service in stable condition, where she received supportive care with IV fluids and continued cardiac monitoring. She responded well to the prescribed therapies and was subsequently discharged in stable condition. 

There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the proposed treatment of Inpatient admission is not deemed medically necessary.