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

The patient is a female with left hemiparesis secondary to cerebrovascular disease.  According to the appeal letter provided by the patient's designee, the patient has been receiving services since 2017 and is going to therapy for treatment related to a 2015 stroke.  The patient's neurology provider has indicated in a 2019 letter that the patient suffered another stroke in 2019, and the patient requires additional home attendant services.  The patient requested personal care hours for a total 70 hours a week.  Her plan approved 42 hours a week, 6 hours a day 7 days a week.  The subject under review is the medical necessity of the additional hours.  The health plan's determination is upheld. 

The requested health service/treatment of increase in consumer directed personal assistance program services (70 hours) is not medically necessary for this patient.

The patient is a female with left hemiparesis secondary to cerebrovascular disease.  The patient has past medical history significant for myocardial infarction along with a stroke affecting the middle cerebral artery with left hemiparesis.  She suffered from a recurrent stroke which was treated with tissue plasminogen activator (TPA), but she had increased left-sided residual weakness.  This was in 2019.

The patient had an evaluation done prior to this in 2019, which noted that the patient required a total of 39 hours a week.  She had subsequent evaluation in 2019, which noted the patient required a total of 36 hours a week.  Another subsequent reevaluation in 2019 with Uniform Assessment System (UAS), State of New York, noted that patient required total 42 hours a week.  At that time her service hours were increased to 42 hours a week, 6 hours a day 7 days a week.  This last evaluation was done after the patient was admitted to the hospital with new stroke symptoms. 

It was noted from the UAS State of New York that the patient's ability to dress upper and lower body along with personal hygiene, bed mobility walking, bathing transfers stayed the same.  Her ability to perform functions such as eating, meal preparation, medication management ordinary housework declined.  In summary, most activities of daily living stayed the same; however, some declined.  At that time hours were increased from 36 hours a week the 42 hours a week.  Additional hours for companionship or supervision were not approved.

Overall, there is been slight decrease the patient's ability to maintain independence.  She did require more time according to the UAS state of New York with predominantly personal hygiene.  The amount of time allowed is sufficient to maintain these needs.  Additional service hours are not medically necessary.

The amount of personal-care service hours, which are listed, 42 hours a week, are adequate to meet the patient's personal-care needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left lower below knee amputation
Issue under review: New left leg prosthesis

Determination:
The New left leg prosthesis is not medically necessary.

There are no documented indications that the patient is able to tolerate wearing a prosthesis.  The patient has had chronic pains.  A detailed narrative history regarding the patient past prosthetic wear and use is not provided.  There are no indications that the patient would be able to don and doff a prosthesis.  Notably, the patient has right hemiplegia and hand contractures and is unable to open medication bottles.  There are, furthermore, no indications the patient has the capacity to tolerate standing or transferring with a prosthesis with respect to the cardiovascular, pulmonary and musculoskeletal systems.  The patient has been using a power wheelchair for mobility and has been dependent for transfers, which would be consistent with very limited endurance and cardiovascular/pulmonary capacity.  The patient has a left knee contracture and only fair left hip and knee strength.  This would preclude safe standing and transferring given the patient hand impairments (i.e., with inability to safely use a walker for balance) and a nonfunctional right lower limb.

The proposed prosthesis is not medically necessary based on the available records.  There are no indications that the patient would be able to use a left transtibial prosthesis in a safe and effective functional manner given her extensive bilateral upper limb and bilateral lower limb impairments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  High blood pressure, Low RBC, diabetes
Issue under review:  Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

It was doubtful that the patient actually had a diagnosis of preeclampsia, but in any case she did not meet criteria for severe features, which would be the threshold for hospitalization.  The documented blood sugars do not support a diagnosis of diabetic ketoacidosis or life-threatening levels of blood sugar either for the fetus or the mother.  The adjustments of insulin infusion could have safely been done as an outpatient, and preeclampsia, if present, can be treated on an outpatient basis, if severe features are not present, as was the case with this patient.  The Venofer infusions can be effectively and safely given on an outpatient basis.  Therefore, the admission is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Opioid Dependence
Treatment: Continued inpatient admission 

The continued inpatient admission was medically necessary for this patient.

The requested 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 heroin with IV administration together with intermittent use of a benzodiazepine anxiolytic (Xanax) and 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 developed moderately severe withdrawal symptoms, and the patient's social environment was not conducive to detoxification, and 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 continued 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 (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 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, 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 continued inpatient detoxification is medically necessary in this case scenario, and therefore should be covered in this case scenario. Specifically, 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 and seizure precautions. Moreover, the continued Substance abuse detoxification treatment through discharge could not have been safely or effectively provided with lower level services. Thus, the Continued inpatient admission should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM Criteria and the New York State LOCADTR 3.0 Criteria, referenced below.
Appeal type: Medical necessity
Decision: Upheld

The patient has multiple medical problems, and a past medical history for a cerebrovascular accident with left-sided hemiplegia. The patient also has noted mild cognitive deficits. The patient requests personal care services increase to 24 hours a day 7 days a week with a split shift. The health plans determination of medical necessity is upheld in whole. The requested health service/treatment of Personal Care Services, increase to 24 hours a day, 7 days a week (split shift) is not medically necessary for this patient. There was no new change in the patient's medical status noted. The change in the personal-care service hours were secondary to the fact that the patient's primary caretaker had illness and was unable to perform services independently of the personal care aide. Therefore, the requested health service/treatment of Personal Care Services, increase to 24 hours a day, 7 days a week (split shift) is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient stay

Summary:
The patient presented with new onset chest pain, suspicious for unstable angina. The patient had a known history of severe premature coronary artery disease, including a recent MI (myocardial infarction), requiring percutaneous revascularization. The ECG was unrevealing for ACS (acute coronary syndrome), but was abnormal, with findings suggestive of prior myocardial infarction. There was a high index of suspicion for an ACS, and further ischemic work-up was planned by cardiology. Given the history of CAD, abnormal stress test, as well as clinical suspicion for an acute coronary syndrome/unstable angina, he would not be an appropriate candidate for an ED chest pain observation unit. It would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Testicular Torsion
Treatment: Inpatient Admission  
The insurer denied the Inpatient Admission. The denial was upheld. 

This is a young male patient who was admitted to the hospital in early 2019 with complaints of left groin pain associated with vomiting. The patient denied any history of trauma to the area.  A Doppler ultrasound was ordered which revealed the absence of flow to the left testicle, and the left epididymis was enlarged and highly vascular.  The patient underwent a scrotal exploration, with left orchiectomy and right testicular fixation.  The patient tolerated the procedure well, and he was discharged home later that day.  

Per MCG Health (22nd Edition) Urologic Surgery and Procedure GRG, the patient is noted to have met the General Recovery Course discharge parameters within 23 hours post procedure.  As per the guideline, this procedure is normally designated for the ambulatory surgery setting.  Per MCG Health (22nd Edition) Orchiectomy, the patient is noted to meet also the Optimal Recovery Course discharge parameter within 23 hours post procedure.

The carrier's denial of coverage for the inpatient admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Fever
Treatment:  Inpatient admission 

The patient is a male infant.  He presented to the ED with fever and decreased intake for one day.  His mother was also sick with chills and cold symptoms.  He was born full term, mother was GBS (Group B streptococcal) negative, but he had not yet received any vaccinations. 

In this particular case, the baby developed fever.  He underwent a partial sepsis work-up in the ED (no lumbar puncture) that revealed infection with influenza A.  He was hospitalized to monitor for progression of symptoms.  He did well and was discharged within 24 hours.  While it was reasonable to observe him closely for decompensation, he was hemodynamically stable, with no signs or symptoms of sepsis or cardiorespiratory instability.  He did not require acute inpatient admission, and he could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Flank pain; shortness of breath
Treatment:  Inpatient admission
The inpatient admission was medically necessary.
The patient presented with symptoms of acute CHF exacerbation, with known severe systolic dysfunction. The patient had known severe systolic dysfunction with EF of 5-15%.  This patient with multiple co-morbidities, including systolic CHF, COPD, and HTN (hypertension), presented with CHF exacerbation and was appropriately treated with IV diuresis.  Given this presentation, acute CHF, as well as multiple risk factors, co-morbid conditions and known CAD (coronary artery disease), it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gender dysphoria-Transgender transitioning (male to female)

Treatment: Breast Enlargement/Augmentation for Male to Female Transition

The insurer denied Breast Enlargement/Augmentation for Male to Female Transition. The denial was upheld. 

This is a patient who several decades ago transitioned from male to female gender. At that time, the patient had undergone a breast augmentation. In early 2019, the patient presented to the plastic surgeon with a large B cup size breast. While the World Professional Association for Transgender Health (WPATH) supports the initial augmentation the patient had undergone decades ago to be reconstructive and medically necessary to promote gender identification for patients transitioning from male to female gender, WPATH standard of care does not indicate whether or not a re-augmentation of an already female-sized breast, such as a large B cup size is purely reconstructive and medically necessary to treat this patient's medical condition.

WPATH Standards of Care v. 7 acknowledges opinions diverge as to what degree of breast reconstruction can be considered purely reconstructive. While this patient provides medical documentation from a qualified mental health provider of persistent gender dysphoria, WPATH's recommendations and guidelines do not address the issue of re-augmentation of an already augmented, female-appearing breast.

The carrier's denial of coverage for the request for breast enlargement/augmentation for male to female transition is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

The patient with a past medical history significant for diabetes mellitus, pulmonary hypertension and pulmonary fibrosis.This review is for the medical necessity of consumer directed personal-care assistant hours.The Health plans determination of medical necessity is overturned in whole. Yes, the requested health service/treatment of Consumer Directed Personal Assistant Program (CDPAP-T1019) x3hours x 6 days and 4 hours x 1 day for a new total of 22 hours per week is medically necessary for this patient.

The recommendation is to approve 22 hours a week based upon the following rationale. There was insufficient information available to make an assessment in regard to decreasing hours from 22 hours per week. In specific no Uniform Assessment system (UAs) state of New York or care plan was submitted for review. It is difficult to ascertain whether the patient requires either 22 hours a week or less a week without this type of documentation. Therefore, it is professional opinion that the patient should be continued with 22 hours a week until further documentation can be provided which shows otherwise.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems
 
Treatment: Orthodontic Treatment (Braces)

The insurer denied Orthodontic Treatment (Braces). The denial was upheld.

This patient is a female child who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying conditions of anterior crossbite and impacted permanent anteriors where extraction is not indicated.  

The insurer has denied coverage for orthodontic treatment as not medically necessary, as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 16 points on review by internal reviewers.  The patient is appealing the decision

Upon review, the clinical information received did not substantiate the need for the requested service.  To assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index.  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 automatic qualifying conditions of anterior crossbite and impacted permanent anteriors where extraction is not indicated.  This reviewer finds that the clinical information did not substantiate the orthodontist's claim of the automatically qualifying condition.  

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies. Each referenced peer reviewed article concludes that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

The healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient.  Comprehensive orthodontic treatment of the adolescent dentition is not considered medically necessary for this patient.

The carrier's denial of coverage for Orthodontic Treatment (Braces) is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

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

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

This male patient was admitted to inpatient substance detoxification treatment due to substance abuse. The patient had withdrawal symptoms including tremors, sweats, teary eyes, sleeping problems, anxiety, as well as an irritable mood, an elevated blood pressure of 138/89 and an elevated heart rate of 98. His Clinical Opioid Withdrawal Scale (COWS) score was 14. The patient had been inhaling a bundle of heroin per day.  The patient was also inhaling cocaine weekly and using Xanax monthly. The patient had other medical issues. The patient was put on a 5-day methadone taper. The patient left against medical advice (AMA).
 
The American Psychiatry Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. This patient had a recent prior substance detoxification treatment and was still using heroin, cocaine, and Xanax; therefore, the patient was at risk for overdose and severe withdrawal. The patient lacked coping skills and required 24-hour detoxification treatment as the patient could not safely and effectively be treated in an outpatient setting. According to the LOCADTR, the patient required 24-hour treatment as the patient needed detoxification medication to modify withdrawal. It was not likely that the patient would have remained abstinent or been able to safely and effectively be treated for further substance detoxification treatment as an outpatient as the patient lacked coping skills for abstinence and for detoxification treatment in an outpatient setting. Also, the patient was in need of 24-hour medical substance detoxification treatment due to his multiple serious substances of use and due to his risk of severe withdrawal if not detoxified properly. 

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

This is a male who was admitted for inpatient detoxification. The patient reportedly had at least 5 prior treatment episodes related to his substance use disorder but had been unable to maintain sobriety. He had an alcohol withdrawal score of 2 and an opioid withdrawal score of 11 the same date. 
His clinical history was significant for numerous past substance use disorder treatment episodes at the detoxification and rehabilitation levels of care. The patient reported having stable housing. His past medical history was negative for a seizure disorder, hypertension, diabetes, human immunodeficiency virus (HIV), asthma, heart disease. He had a history of depression and was on medication for depression. He did not have any type of hepatitis. The patient was placed on a methadone taper for the opioid withdrawal. He was also placed on a Librium taper for the alcohol withdrawal. The health plan's determination is upheld. The inpatient detoxification was not medically necessary. The concurrent review module of Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) was used to evaluate treatment at the medically managed or medical supervised detoxification level of care. There had been no changes in the patient's status that would require a higher level of care. The withdrawal no longer continued to require 24-hour oversight in a hospital setting due to serious and life-threatening complications. The withdrawal no longer required 24-hour medical supervision, stabilization, and regular vital sign monitoring in a medical setting. As per this module, the patient did not meet criteria for continued care at the inpatient detoxification level of care.