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

Diagnosis: Substance abuse
 
Treatment: Inpatient detoxification treatment, medication, monitoring

The insurer denied the continued inpatient substance detoxification treatment. The denial was reversed.

This male patient was admitted to inpatient substance detoxification treatment for alcohol detoxification. He had multiple withdrawal symptoms, a blood pressure of 144/84, and a CIWA of 14. The patient reportedly had a history of several decades of alcohol use and was drinking four 24 ounce cans per day. He had over a decade of crack use and was smoking tens of dollars' worth per day, and over three decades of cannabis use daily. He had a positive toxicology screen for cocaine and cannabis. The patient was put on a Librium protocol and was discharged with a referral to inpatient rehabilitation treatment. 

The 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. This patient was using multiple substances and had a long history of use. He could not stop using these substances and alcohol on his own. He was at risk for overdose and at risk for severe, complicated, and life-threatening withdrawal symptoms due to the amount of alcohol and substance use. The patient required the entire detoxification protocol as he was at risk for severe withdrawal symptoms if he stopped the detoxification treatment prematurely and possibly complicate his withdrawal. According to the LOCADTR he required 24-hour treatment as he needed and received detoxification medication to modify withdrawal and prevent severe, complicated, and life-threatening withdrawal. He had relapsed after past inpatient substance treatments, so he was at high risk for relapse again. 

Based on the above, the medical necessity for the continued inpatient services is substantiated.  The insurer's denial is reversed.
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 continued inpatient admission could not have been effectively provided at a lower level of care in this case scenario. The patient in this case was using heroin with five bags daily and was using PCP daily that did warrant the admission and the continued inpatient level detoxification with withdrawal management and inpatient level monitoring. Detoxification with a methadone taper, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been 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 including persistent anxiety and elevated blood pressures that were being effectively addressed with methadone and supportive measures and PRN medications provided during the time interval under review. The patient presented with a lack of sober supports and limited insight, impaired judgment and poor control of impulses that also supported the continued inpatient level detoxification in order to prevent relapse and complete his detoxification which allowed for his preparation for a recovery effort and referral to rehabilitation services. 

Thus, the continued detoxification treatment of this patient's substance use disorders did warrant and require 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 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 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/Guidelines-referenced below.
The requested benefit of continued inpatient admission is clinically appropriate, medically necessary and warranted, and is therefore a covered benefit in this case scenario. The continued inpatient level treatment through discharge could not have been effectively provided with lower level services, 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 consideration of ASAM Criteria and application of NY State OASAS LOCADTR 3.0 Criteria, referenced below.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for chronic systolic heart failure, diabetes mellitus, dementia, depression, atrial fibrillation, hypertension, sick sinus syndrome, transient ischemic attacks and repeated falls.  Personal care services are requested; currently she is receiving 12 hours a day 7 days a week for a total of 84 hours a week.  A live in personal care aide secondary to increased fatigue and decreased endurance is requested. 
The health plan's determination is upheld.  Assessment noted that the patient needed limited assistance with bed mobility and eating.  She required extensive assistance with personal hygiene, dressing upper body, walking, locomotion, toilet use and transfer.  The patient required maximal assistance with meal preparation, medication, phone use, bathing, lower body dressing. The patient was totally dependent with housework, finances, stairs, shopping and transportation. She was noted to be occasionally incontinent of bladder control.
She was noted to have an adult child who lives locally and is willing to provide additional services or assistance as needed.  A Uniform Assessment (UA) state of New York was performed.  The tasking assessment noted that the patient required a total of 12 hours a day 7 days a week for 84 hours a week of care.  The patient required assistance with services from broad range of instrumental activities of daily living (IADLs) and activities of daily living (ADLs).  However, the allotted time is sufficient to meet these needs. There are no services noted that would be considered medically necessary that cannot be performed within the allotted time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Obesity
Treatment:  Revision surgery
The revision surgery is medically necessary.
The proposed revision of a gastric sleeve is medically necessary and appropriate therapy for this patient.  This patient has a documented complication or technical failure of a sleeve gastrectomy that was performed in another country in 2009.  This technical failure is documented by upper endoscopy and is a significant contributor to her refractory morbid obesity.
The documentation provided does support that the proposed revision of the sleeve is better than alternative non-surgical therapeutic options for this patient.  This therapy is a standard intervention for a patient who has undergone sleeve gastrectomy, yet has retained gastric fundus and cardia.  This patient has been appropriately evaluated with upper endoscopy, mental health evaluation, medical consultations, lab assessment, and she has participated in a supervised weight loss program over a period of more than six months.  Revision of the gastric sleeve will provide the necessary restriction and satiety that, in conjunction with ongoing dietary compliance, will promote sustained weight loss of 50-60% of excess body weight. 
In this case, there is appropriate documentation of technical failure that has resulted in refractory morbid obesity.  Revision and correction of the prior sleeve surgery as proposed by Dr. Holover is medically necessary, and is consistent with the standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast cancer 
Treatment: Revision of reconstructed breast, and tissue grafting

Revision of the reconstruction is medically necessary.  

This female has undergone post mastectomy breast reconstruction.  Revision is planned with codes 19380 and 20926.  She has contour depressions in the superior and medial aspects of her breasts. 

The Women's Health and Cancer Rights Act mandates coverage for all stages of breast reconstruction. The following is quoted directly from the US Department of Labor website regarding the WHCRA (1):

"Under WHCRA, group health plans, insurance companies and health maintenance organizations (HMOs) offering mastectomy coverage must also provide coverage for certain services relating to the mastectomy in a manner determined in consultation with the attending physician and the patient. Required coverage includes all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses and treatment of physical complications of the mastectomy, including lymphedema."

The patient has continued deformities following her breast cancer reconstruction. Her deformities are due to her breast cancer, and correction of the deformities is a stage of her reconstruction. The plastic surgery literature has several studies that show that outcome of breast reconstruction can change over time due to age and weight gain and loss.  Particularly with implant reconstructions, the quality of the reconstruction can change and implants can rupture. Breast reconstruction is not a one-time and done forever procedure. Revisions are commonly required and can reasonably be considered a stage in breast reconstruction which is now understood to be a multi-stage process including revisions.  Fat grafting and breast revision are stages of her reconstruction to restore her breasts to her pre-mastectomy appearance.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Cushing's disease with secondary hypogonadism
Treatment: Testosterone 2.5g-1.62% gel packet

The health plan should not cover the formulary exception for testosterone 2.5g-1.62% gel packet.

Summary:
The patient is a male with Cushing's disease with secondary hypogonadism. He has tried and failed testosterone injections due to injection site pain. Patient has tried and had success with AndroGel. 

This patient has tried and failed injectable testosterone, and therefore, the formulary alternatives testosterone cypionate or testosterone enanthate are not appropriate alternatives. However, this patient does not have a documented trial of testosterone transdermal gel 25 mg/2.5 g (1%) or testosterone transdermal gel 10 mg/act (2%) or contraindication to these alternatives and these alternatives are indicated for treating male hypogonadism. The Endocrine Society guidelines on the management of male hypogonadism do not support the requested testosterone 2.5g (1.62%) over the formulary alternatives. Therefore, no, the health plan should not cover the proposed treatment.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for Alzheimer's disease, ambulatory dysfunction, diabetes, hypertension and chronic kidney disease.  Personal Care Services 12 hours day 7 days a week are requested.  At issue is the medical necessity of these services.
The health plan's determination is upheld.
The patient has multiple medical problems most significantly Alzheimer's disease, ambulatory dysfunction, diabetes, hypertension chronic kidney disease.  It is noted from his medical record that he has had a progressive decline in his mental status and function.  Personal Care Services 12 hours day 7 days a week is being requested.   Currently he has been approved for 5 hours a day 7 days a week.  The Uniform Assessment System (UAS) documentation noted that the patient needed help with personal care needs including preparing meals, housekeeping, laundry, shopping, managing medications, dressing, bathing, personal hygiene and toiletry.  The patient does have some noted incontinence of bladder but not stool.  This has been managed with pullups/adult incontinence products.  No recent falls were noted.  The documentation provided noted that the patient required a total of 25 hours per week of services.  The patient currently has been approved for 35 hours a week.  A current reassessment showed no significant change in the patient's underlying function.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease
 
Treatment: Inpatient admission 

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

The patient is a man with a past medical history of coronary artery disease, hypertension, hyperlipidemia, peripheral artery disease, and valvular heart disease. He presented for an elective percutaneous coronary intervention. The patient received a drug-eluting stent to the left anterior descending artery. There were no procedural complications, and the patient was then admitted for further monitoring. The patient remained hemodynamically stable, was ambulatory, and tolerating oral intake. There were no vascular access complications. The patient was subsequently discharged home after an uneventful, brief overnight hospital stay. 

Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this procedure is an outpatient one. The clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate. There were no extenuating circumstances in this case which warranted inpatient admission status following elective cardiac catheterization and attempted angioplasty. 

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

The patient was referred to the emergency department (ED) with two-week history of fevers to 104, started on amoxicillin five days prior by the pediatrician for a virus per the mother without improvement. The patient has had three-day history of cough with decreased air entry over the right lower lung field, and one-day history of vomiting and diarrhea. The patienthad no past medical history and no recent travel. Vital signs included temperature 102.3, heart rate 116, respiratory rate 24 with 98% saturation, and blood pressure 139/71. He was treated with ceftriaxone and azithromycin and admitted for further evaluation with diagnosis of leukopenia. He continued to spike fevers despite antibiotics.

The health plan's determination is overturned. The inpatient stay was medically necessary. Prolonged fever is not an uncommon presenting complaint in pediatrics. Fever of unknown origin is defined as fever of 38C or more for more than seven days without an identified source. There are four broad etiologic categories: infectious, autoimmune, oncologic, and other/unknown. In a significant percentage, the etiology is not identified and the fever resolves. In certain instances, the etiology may be life-threatening. This patient presented with prolonged fever as well as transient constitutional and respiratory symptoms. The patient failed management with antibiotics in the outpatient setting, had hepatosplenomegaly on exam, and manifest progressive leukopenia/neutropenia over the course of his hospital stay. There was reasonable concern for malignancy (lymphoma, leukemia) as well as serious infection. The patient underwent comprehensive infectious disease work-up including evaluation for diseases not often seen in the US (United States) (eg malaria). In the absence of infectious etiology and presence of salmon-colored rash with fevers, rheumatologic etiology was also considered (eg systemic juvenile idiopathic arthritis), hence the transfer to an institution with appropriate subspecialty consultation. Timely evaluation of this patient would not have been possible in the outpatient setting. Further, daily monitoring revealed the presence of rash. The acute inpatient stay was medically necessary and appropriate. This child could not have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The wound was debrided, and a wound VAC was re-applied.  The patient could have been discharged home that evening or at the latest the next morning.  The orthopedic note on stated that the discharge was appropriate.  IV antibiotics were not indicated, as there was no determined infection and oral antibiotics would have been appropriate.  This could have been provided at a lower level of care.

There was no evidence to show that an extended hospital stay beyond the next morning was necessary, and inpatient admission was not medically necessary for this patient at any time during the dates under review.  The patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's disease and cardiac disease
Treatment: Increase in personal care assistance services from 28 to 35 hours per week

The increase in personal care assistance services from 28 to 35 hours per week is not medically necessary based upon available medical records and documents.

Based upon a review of the medical records and documents provided, including the community assessment, the patient's medical needs are being met by the current PCA schedule of four hours per day seven days per week.  After complete review of all documentation, fatigue and decreased endurance does not require additional hours of skilled PCA.  Based upon available documents and medical records, current PCA staffing meets the patient's medical needs.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department for evaluation of recurrent palpitations with recent associated near syncope and chest pain. Past medical history includes coronary artery disease (CAD) status post coronary artery bypass graft (CABG), hypertension, hyperlipidemia, diabetes and asthma. The physical examination was significant for 1+ bilateral lower extremity edema. Laboratory data revealed microcytic anemia, hyperglycemia, and normal cardiac biomarkers. The electrocardiogram (EKG) revealed normal sinus rhythm and nonspecific T wave changes. The patient was admitted for management of palpitations and near syncope. Serial troponin ruled out acute coronary syndrome. The echocardiogram revealed normal left ventricular function and absence of significant valvular disease or regional wall motion abnormalities. The stress test was normal, and a loop recorder implantation was done. The patient remained stable and was discharged. Documentation does not meet medical necessity for inpatient level of care. Vital signs were stable, and the physical exam noted 1+ lower extremity edema but was otherwise unremarkable. Acute coronary syndrome was ruled out and there was no clinical evidence of pulmonary embolism or thoracic aortic dissection. The echocardiogram was negative  and stress test was normal. The patient could have been adequately managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

This patient is a pediatric patient with a history of ulcerative colitis. Patient being treated with Remicade (infliximab) high dose (10 milligrams (mg) per kilogram (kg) every 4 weeks). On the current dose, patient continues to have occasional abdominal pain, diarrhea and bloody stools. The treating physician requested measurement of Remicade level and antibodies. The test showed a low Remicade level at 3.1. The requested service is for Remicade dose increased to 15 mg per kg per dose every 4 weeks. the requested treatment of Remicade is medically necessary for this patient. This patient did not have an adequate response on the current dose and has a documented low drug level. The higher dose requested is likely to improve the drug level and increase the chances of clinical response. It is common practice in the management of inflammatory bowel disease to try to rescue the treatment by increasing the dose frequency or increase the dose (dose escalation). It is generally acceptable to use Remicade drug levels as a guide to help the physician adjust the dose. This practice is very commonly used in biologic treatments in general including infliximab. There are many peer reviewed literature reports showing that low infliximab levels were associated with poor clinical response. Literature reports and the standards of care support the practice of dose escalation. The Food and Drug Administration (FDA) label of Remicade include dosing up to 10 mg per kg per dose but sometimes, a higher dose is required to improve the drug level. The plan`s determination of medical necessity is overturned.
Appeal type: Medical necessity
Decision: Overturned

The patient is a female who presented to the emergency department on with abdominal pain, and her history and physical exam and imaging were consistent with acute appendicitis. She was taken to the operating room the next day for an uncomplicated laparoscopic appendectomy. At the time of the operation, the surgeon noted gangrenous appendicitis. She remained hospitalized on intravenous antibiotics with fevers until discharge. 

Review of the chart demonstrates a doctor's progress note indicating that the patient was taking minimal oral fluids. She had been febrile overnight. There are no other doctor's notes in the chart. Nursing notes in the chart document a fever on two days and a maximum temperature of 38.2 Celsius (C) on another day. She was deemed ready for discharge home. Pathology noted "severe appendicitis" but not perforated.

The health plan's determination is overturned, in whole. 

Based on the nursing notes, this patient was febrile for the entire stay on two days.  It is common practice and standard of care to keep patients in the hospital after appendectomy until they are afebrile for 24 hours. This is what was done in this case. It is also quite reasonable to expect that a patient with gangrenous appendicitis with phlegmon formation will have a need for acute inpatient care and the necessary intravenous antibiotic therapy and close monitoring that is provided at the acute inpatient level of care.

This patient required inpatient acute care for this condition. In the very recent manuscript by Nordin et.al., the authors indicate that gangrenous appendicitis is often grouped with and managed as complex, perforated appendicitis. The authors also demonstrate that those pediatric patients with gangrenous appendicitis typically have required a more prolonged stay, on average 2.5 days inpatient (with some requiring longer stays). Therefore, the most recent literature is completely consistent with the management of this child as an inpatient as was done.