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

Diagnosis: Alcohol Abuse
 
Treatment: Inpatient substance detoxification Admission

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


This is a middle aged male was admitted to inpatient substance detoxification treatment in early 2019 for alcohol detoxification. He reportedly had alcohol withdrawal symptoms including nausea, tremors, sweats, yawning, irritable mood, sleeping problems, joint pain, anxiety, headache, elevated blood pressure, and cravings. He reportedly had a history of alcohol use-drinking up to 2 pints of liquor per day for over two decades. He had a medical history of hypertension and bariatric surgery. He was put on a Librium protocol and took Librium for detoxification medication during this admission. He reportedly was discharged and agreed to inpatient substance rehabilitation treatment.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24 hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use alcohol and was unable to maintain abstinence, and he needed detoxification medication (Librium) to modify withdrawal from alcohol and received it during this admission and then was discharged to attend 24 hour inpatient substance rehabilitation treatment.  He needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including possible life threatening withdrawal such as delirium tremens.  The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required the time in this hospital as he was considered at high risk for life threatening withdrawal.  He could not stop drinking and had reports of limited coping skill and identification of relapse triggers, difficulty dealing with stressors, and could not maintain abstinence on his own.  There was enough evidence to support that he required a 24 hour inpatient medical detoxification treatment then.

The carrier's denial of coverage for the inpatient hospital services at the inpatient level of care from is substantiated.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the Hospital emergency department (ED) in early 2019 as a trauma activation with a gunshot wound to the left arm. The patient was awake and alert at the time of presentation. There were two wounds to the left arm proximal to the elbow. One wound was to the posterior arm and the other was in the medial arm. There was an abrasion of the chest wall over the body of the sternum.

The health plan's determination is upheld. The inpatient admission was not medically necessary. The records support that a lower level of care would have appropriately satisfied the clinical needs of this patient. This patient presented as a trauma patient with gunshot wounds to the chest and left arm. He was clinically stable at the time of presentation. The initial evaluation did not identify intra-thoracic or left arm vascular injury. This patient did not require emergent surgery or the coordinated care of multiple medical/surgical services. The medical and nursing progress notes document clinical stability during the course of inpatient care.
A lower level of care would have been clinically appropriate and would have been consistent with the accepted standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient admission 
The inpatient admission was not medically necessary. 

This is a male with a history of polysubstance abuse who presented to the ER for further evaluation/management for opiate/benzodiazepine withdrawal/detoxification. His intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. His examination was non-focal, with no significant abnormalities noted, including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen. 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 he received supportive care with IV fluids and continued cardiac monitoring. He 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 Inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient presented with syncope, and fever who presented to Nyack hospital. No fever was noted in the emergency department (ED), however the heart rate (HR) was 103. Pulse ox was 99 on room air (RA) initially. However, a lower SpO2 of 90 on RA was recorded in the records. The basic metabolic panel (BMP) was normal. The complete blood count (CBC) showed leukocytosis of 18k. The patient was 6 weeks s/p allograft repair of the right knee. The patient was treated with intravenous (IV) fluids, and a computed tomography (CT) angiogram to rule out pulmonary embolism (PE). The patient also had a negative ultrasound (US) exam. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. After the work up of the PE from the ED was negative, the patient did not need an acute level of care. Once a PE is ruled out, the IV antibiotics could have been administered at a lower level of care. Even though the initial tachycardia, and chest pain was concerning for the PE, the CT scan and the US were negative. The patient had leukocytosis and fever. The tachycardia was from the fever. Blood culture was negative. An electrocardiogram (EKG) was negative. The Allograft from 6 weeks ago can be a source of pain but there was no infection. There is no immunosuppressive therapy for allograft; this allograft is not a true transplant hence the risk stratification for a transplant is not applicable here. Also there is not one case report in the literature that allograft has suffered infection after surgery. The treating providers discharged him the next day as there was no concern for allograft infection.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee Pain
Treatment: MRI - code 73721
The MRI without contract is not medically necessary.

MRI utilization is of benefit if additional information assists in establishing a diagnosis. The scientific literature describes MRI should be recommended if conservative treatment has not been beneficial. The diagnosis can alter the decision, prognosis and plan of care. The necessity for more invasive procedures (surgical treatment) can be assessed.

The performance of the MRI should have an impact on a patient's treatment regimen. If diagnostic tests are not clinically useful, they are not medically indicated.

The medical record denotes new onset of knee pain. There was no description of injury or trauma. There was no physical examination which showed positive findings. There was no differential diagnosis provided. The reasoning being "knee pain and partial ACL 2014" are insufficient to substantiate this test. The patient had not received conservative treatment. There was no indication of surgery. 

There were no extenuating circumstances to substantiate need for MRI at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission

The Inpatient admission was not medically necessary.

For symptomatic gallstones, in accordance with guides from the Society of American Gastrointestinal and Endoscopic Surgeons [SAGES], whether the patient had surgery during this presentation or in the future, he could have been treated at a lower level of care. SAGES states: "Patients undergoing uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis may be discharged home on the day of surgery." 

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

The patient is a female with a complaint of right knee pain.  The patient initially sought treatment in 2017 for chronic right knee pain. The patient reported no traumatic injury and no mechanical symptoms in the right knee on this visit. A cortisone injection was administered, and the patient had excellent pain relief for months. Recurrent right knee pain was reported in 2018, at which time a second cortisone injection was given for her right knee arthritis. The provider also recommended weight loss. A third cortisone injection was administered. This was followed by a course of Euflexxa injections completed in 2018. The patient continued to complain of right knee pain despite the Euflexxa injections, so a magnetic resonance imaging (MRI) scan was obtained, which revealed medial and patellofemoral arthritis and a horizontal tear of the posterior horn of the medial meniscus. A follow up examination was performed at which time x-rays of the right knee were done confirming medial and patellofemoral arthritis in the right knee. The provider requested approval for right knee arthroscopic partial medial meniscectomy in this patient. This procedure was denied by the plan.

The health plan's determination is upheld.

The rationale for this determination is based on the provided medical records, which do not document any attempted physical therapy to remedy this patient's knee pain. In addition, the weight-bearing knee radiographs demonstrate near bone on bone deformity in the medial and patello-femoral knee compartments. The current, peer-reviewed literature does not endorse the performance of knee arthroscopic partial medial meniscectomy surgery in this scenario.

There is no documentation of supervised physical therapy attempted by the patient in question prior to the request for arthroscopic meniscal surgery in this case. Therefore, the request for authorization of arthroscopic meniscal surgery is not medically necessary, as this is not consistent with the recommendations of the current, peer-reviewed literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Abuse
 
Treatment:  Inpatient Substance Use Rehabilitation

The insurer denied the Inpatient Substance Use Rehabilitation.  The denial was reversed.    


This is a female patient who was admitted to inpatient substance rehabilitation treatment in 2019 for substance rehabilitation treatment.  She reportedly was using alcohol, cocaine, cannabis, and had a positive toxicology for cocaine and cannabis.  She was noted to have had past inpatient substance detoxification and rehabilitation treatments and still was unable to remain abstinent.  She attended individual and group therapy with success and was discharged.
The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting.  In this case this patient was considered in need of 24-hour substance rehabilitation treatment, as she was using alcohol and multiple substances including cocaine and cannabis, and she was considered at risk for severe and life threatening complicated withdrawal or overdose due her use.

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

Diagnosis: RSV
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient presented to the ED at the peak of his RSV illness with signs and symptoms consistent with bronchiolitis. He was placed on BiPAP in the ED (CPAP was not available) and was able to wean quickly to room air. He responded well to bronchodilators, raising suspicion for possible asthma. He remained hemodynamically stable throughout his hospital stay. While he clearly required treatments in the hospital, he did not require acute inpatient admission and could have been safely managed at a lower level of care. 

While the child had been seen in the ED two days prior to admission, there is no indication that he was given any treatments for home use (e.g., nasal saline for congestion, albuterol for wheezing). He was tested and given a diagnosis of RSV. This is not a failure of outpatient therapy, because there was no home therapy prescribed. In fact, on the day of presentation, he had been taken to daycare, and the concern arose with the vomiting and diarrhea.
Appeal type: Medical necessity
Decision: Overturned in Part

The patient was  brought to the emergency department with one week of a fever, non-bilious/non-bloody vomiting, and non-bloody diarrhea. She received two normal saline boluses, appeared better, took formula by mouth, and was sent home with follow up instructions. The parents returned with her to the ED about twelve hours later, for a possible febrile seizure versus shaking chill.  The baby appeared well except for dry mucus membranes. She was given two normal saline boluses and begun on two-times maintenance intravenous (IV) fluids and admission to the hospital was arranged. The health plan's determination is overturned in part.
This baby returned to the ED twelve hours after having received significant IV fluid therapy in the ED. Upon representation, her fluid status was worse, as evidenced by the dry mucus membranes and the much lower bicarbonate level. Given the representation with worsening dehydration despite appropriate therapy, now with significant acidosis, further IV fluid therapy and acute hospitalization was medically necessary. That first day, acute criteria were met and acute inpatient hospitalization was necessary. By the next day, however, she was improved and taking fluids by mouth. She no longer had clinically significant dehydration and could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 Diabetes Mellitus
 
Treatment: Dexcom Transmitter

The insurer denied the Dexcom Transmitter. The denial was reversed.  

This case involves a female patient currently diagnosed with type 2 diabetes mellitus.  The letter of medical necessity notes that the patient has been using the Dexcom G6 device which was originally prescribed in late 2018 for her hypoglycemia.  Since the beginning, the patient has had improvement from 13% of her blood glucoses to 1%.  The patient does have hypoglycemia unawareness and has come to rely heavily on the Dexcom device.  This is beneficial because the last report states that the patient was still having 4% lows, especially at night when she is sleeping.  The device allows customized alerts for glucose readings outside of target range with interstitial glucose readings every five minutes.  The device provides graphs that offer historical trend data and are visible to help prevent episodes of hypo-/hyperglycemia. It predicts alerts that will alarm up to 30 minutes prior to a high or low blood sugar. The appeal letter noted that a Dexcom clarity report was provided that shows greater than 70% use of the continuous glucose monitoring system device.  The patient utilizes the device 96% of the time and relies heavily on it due to hypoglycemia unawareness, especially nocturnal hypoglycemia.  The transmitter only has a lifespan of three months; therefore, every three months, a new transmitter is needed to be able to utilize the Dexcom sensors.


The medical literature notes that the Dexcom G6 Continuous Glucose Monitoring System (Dexcom G6 System) is a real time, continuous glucose monitoring device indicated for the management of diabetes in very well persons age 2 years and older. The Dexcom G6 System is intended to replace fingerstick blood glucose testing for diabetes treatment decisions. Interpretation of the Dexcom G6 System results should be based on the glucose trends and several sequential readings over time. The Dexcom G6 System also aids in the detection of episodes of hyperglycemia and hypoglycemia, facilitating both acute and long-term therapy adjustments. The G6 CGM Transmitter is a miniature radio transmitter that incorporates data processing functionality. The transmitter contains a Bluetooth radio transceiver for communication with a compatible display device (i.e., receiver and/or smart device). The transmitter attaches to the sensor and can be re-used for multiple sensing sessions up to three months. 

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

Diagnosis: Cough; Dyspnea
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient did not have fever, hypoxia, or hemodynamic instability.  There was no failure of outpatient antibiotic therapy.  The white blood cell count remained normal.  Hemodialysis was performed without complication.  There was no evidence of acute myocardial ischemia.  The patient did not have poor pulmonary edema, hyperkalemia, uremia, or acidosis.  Only a small to moderate pericardial effusion was noted on echocardiogram and it was not accompanied by evidence of cardiac tamponade.  No intervention for this was required.  

In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment and in the best interest of the patient in making its determination.
Appeal type: Experimental/Investigational
Decision: Overturned

This is an elderly male patient who has a history of chronic uncontrolled open angle glaucoma. The patient has tried and failed multiple ocular medications.  He developed an allergy to Alphagan P, which also limited drop therapy options.  The patient had a trabeculectomy glaucoma surgical procedure in his left eye in early 2011. The patient decided against a trabeculectomy in his right eye and had discussion regarding the placement of an Ahmed valve to better control his glaucoma, but the risk of double vision was too great.  The XEN procedure is best option to control the patient's intra-ocular pressure and to limit further vision loss and progression. The patient had the XEN implanted in late 2018.  
An international multicenter retrospective study has recently been published that compares the efficacy, safety, and risk factors for failure of standalone XEN45 gel stent implantation versus trabeculectomy, both with adjunctive MMC.  In this study by De Gregorio et al. (2018), 354 eyes with uncontrolled glaucoma and no prior incisional filtering surgery underwent Microstent implantation (n 185) or trabeculectomy (n 169).  The results demonstrated that there was no difference in efficacy, risk of failure, and safety profile between the 2 surgical procedures.
The XEN glaucoma treatment system is Food and Drug Administration (FDA) approved. This patient is a good candidate for the XEN stent as he has chronic uncontrolled open angle glaucoma which has been refractory to maximal medical therapy.  Given the risks and benefits of standard glaucoma treatments/procedures, the requested XEN get stent is likely to be more beneficial than any other identified treatment options for this patient.   
                                                  
The carrier's denial of coverage for code 0449T- Insertion of aqueous drainage device, without extra-ocular reservoir, internal approach, into the sub conjunctival space; initial device (XEN Glaucoma Treatment System) performed on the right eye should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

This case involves an elderly male diagnosed with primary open angle glaucoma (POAG).  The patient was seen preoperatively in late 2018.  The patient had right eye intraocular pressures of 16 and 15, visual acuity was 20/20.  The patient had progressive open-angle glaucoma to the right eye. The patient has been tried and failed on multiple ocular medications. He developed an allergy to Alphagan P which limited drop therapy options. The patient was a candidate for the XEN procedure to manage his glaucoma due to failed medical therapy. He had a history of left eye trabeculectomy glaucoma surgical procedure in early 2011.  After discussion, it was decided against a trabeculotomy to the right eye.  An Ahmed valve was discussed, but the risk of double vision was too great.  His best option to control his intraocular pressure and to limit further progression of vision loss was the XEN procedure.  

The medical literature notes that the ab interno placement of the XEN gel stent offers an alternative for lowering intraocular pressure in refractory glaucoma as a final step, and in patients intolerant to medical therapy as an early surgical approach with minimum conjunctival tissue disruption, restricted flow to avoid hypotony, and long-term safety.  The documentation indicated that the patient has tried and failed multiple ocular medications with development of an allergy to Alphagan P.  The patient declined the use of other procedures due to the risk of side effects. The patient has had a trabeculectomy.  The patient would require treatment due to the progression of glaucoma despite medical therapy.  The scientific evidence and peer-reviewed literature does support a result of improvement in health outcome. The patient is a good candidate and it would be the best available treatment for the patient at this time.  

The carrier's denial of coverage for code 0449T- Insertion of aqueous drainage device, without extra-ocular reservoir, internal approach, into the sub conjunctival space; initial device (XEN glaucoma Treatment System) performed on the right eye should be reversed.