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

Diagnosis: Abdominal pain, gastritis
 
Treatment: Inpatient admission, medication, monitoring
The insurer denied the inpatient admission. The denial was upheld.
The patient presented with epigastric pain and dysphagia. She was afebrile and vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. An endoscopy revealed a normal esophagus and mild gastritis. The patient was treated with Protonix and the diet was advanced.
The clinical indications for admission for undiagnosed abdominal pain (M-05) include the need for surgery that cannot be performed on an ambulatory basis, and peritoneal signs.
The patient did not have these conditions. She also did not have hemodynamic instability, intestinal obstruction, severe electrolyte abnormalities, or an inability to maintain oral hydration.
MCG- GAS lists indications for admission for Gastroenterology. Severe dysphagia is an indication for admission if it is accompanied by a complicating factor. This can be esophageal perforation, severe dehydration, hemodynamic instability, severe electrolyte abnormalities, or acute renal failure.  The patient did not have these conditions. The endoscopy revealed a normal esophagus. 
This patient was found to have gastritis. She responded to proton pump inhibitor (PPI) therapy. She was stable and could have had an outpatient endoscopy. She did not meet MCG criteria for admission for either Gastroenterology or undiagnosed abdominal pain. She could have been managed with Observation status. 
Based on the above, the hospital admission was not medically necessary. The previous denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Relapsing fever
Treatment:  Kineret
The treatment with Kineret is medically necessary.

The patient is a female with a history of undifferentiated Systemic Autoinflammatory Disease (uSAID).  She has symptoms including fevers, rashes and delayed development.  Her pediatric rheumatology provider has written to start anakinra to treat her uSAID.

The reason given for denying the medication was that anakinra does not have a FDA approved indication to treat uSAID.  Despite this, anakinra has been used safely and effectively to treat similar patients with this condition (see references #1-5 below).  Treatment with anakinra would be considered standard of care in the pediatric rheumatology community for patients with uSAID.  Therefore, approval of anakinra is recommended for this patient with uSAID for a duration of 24 months.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with an eating disorder who was referred and re-admitted on to partial hospital program (PHP) level treatment.  The patient has a complicated history of an eating disorder characterized by restricting intake and over-exercising.  Upon admission she was approximately 102 lbs and had lost 15 pounds while participating in an intensive outpatient program (IOP) which had followed a brief PHP stay at the same treatment facility. The health plan's determination is overturned.
The requested health service/treatment of partial hospitalization mental health treatment - 5 days a week, 6 hours a day is medically necessary for this patient.  The patient could not be effectively treated at a lower level of care.  The patient has failed to respond to clinically appropriate, intensive treatment in the community at the outpatient (IOP) level of care; thus, the treatment plan with respect to PHP level care addressing disordered eating and related disturbances, meal portioning/monitoring, anxiety and obsessive compulsive related disorders, and other interventions to address the severe psychosocial stressors with safety monitoring are reasonable in this case scenario.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sleep Disorder
 
Treatment: Sleep Study

The insurer denied the coverage for a sleep study. The denial was reversed.
This case involves a female who was seen for a follow-up.  The patient does have a history of Hashimoto's thyroiditis as well as shoulder pain, fatigue, insomnia, and arthralgias.  The patient states she felt very tired and drowsy throughout the day.  She wakes up every 30 minutes or so.  She states she snores and snorts during sleep.  The physician indicated the patient should undergo laboratory studies as well as a sleep study due to the fatigue and as of daytime somnolence.  The physician noted this patient does have a history of sleep disorder for several years.  She has insomnia causing fatigue and excessive daytime drowsiness.  She has had a trial of failure of over-the-counter prescription sleep aids without benefit.  According to the medical peer reviewed literature, a full night polysomnography (PSG) is recommended for the diagnosing of suspected apnea related breathing disorders.  Apnea related breathing disorder symptoms may include witnessed apneas; snoring, gasping, and choking at night; excessive sleepiness not explained by other factors; non-refreshing sleep; sleep fragment/maintenance insomnia; nocturia; morning headaches; decreased concentration; memory loss; decreased libido; and irritability.  Within the submitted documentation it was noted that this patient had complaints of constant fatigue as well as myalgias.  

Based on the above, the medical necessity for a sleep study is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain
Treatment: 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 alcohol on a daily continuous basis together with daily use of cocaine that did warrant inpatient level detoxification and withdrawal management and monitoring. Detoxification, as necessary, and other treatments pertinent to the substance use disorder 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 an effective detoxification, and the patient struggled initially with withdrawal symptoms in the context of limited insight, impaired judgment and poor control of impulses.

Thus, the adult inpatient stay and detoxification treatment of this patient's substance use disorders did warrant the continued structure of an inpatient level setting with structure, supports, and 24-hour monitoring. The patient's history of substance abuse (frequency and quantity) does clearly reflect the seriousness of the substance use disorders, and does support the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure or general medical complications such as seizures 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, American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, and, consistent with New York State instruction for medical necessity reviews including the appropriate application of NY OASAS LOCADTR 3.0 Criteria.
The requested continued inpatient admission is clinically appropriate, medically necessary and warranted/necessary for this patient, and therefore should be covered in this case scenario. The Substance abuse detoxification for alcohol and continued inpatient level treatment through discharge could not have been safely or effectively provided with lower level services, as noted above. Thus, the requested benefit should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM Criteria and NY OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.
Appeal type: Medical necessity
Decision: Upheld

The patient received medically supervised detoxification level of care.  The patient was admitted with a blood alcohol level of 188. Vital signs were significantly elevated at the initial evaluation in the patient did have a Clinical Institute Withdrawal Assessment (CIWA) score of 12 early in the admission. Initial diagnoses were alcohol dependence with withdraw; cannabis abuse; nicotine dependence; bipolar disorder; depression, elevated blood pressure without diagnosis of hypertension, asthma. There was no documented history of alcohol withdrawal seizures or delirium tremens. The patient was placed on a Librium taper. Clinical documentation indicates that after the last covered day the patient had minimal or no alcohol withdrawal symptoms. Vital signs were normal and stable. The patient had no unstable medical or psychiatric problems. A Nursing progress note describes the patient as alert and oriented with steady gait. The patient had no complaints. The HP determination is upheld in whole. The inpatient detoxification services were not medically necessary after the HP last covered day. The patient was admitted for alcohol detoxification. The patient did have significant alcohol withdrawal symptoms. The concurrent module of the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) tool was used to determine whether care was medically necessary after the last authorized day. There had been no changes in the patient's status that would require a movement to a higher level of care. The patient did not require continuous 24 hour medical oversight due to serious or life-threatening conditions. The patient did not require 24 hour supervision and stabilization and regular vital sign monitoring. According to the tool, the patient did not meet criteria for medically supervised detoxification.
Appeal type: Medical necessity
Decision: Overturned

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

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

This male was admitted to inpatient substance detoxification treatment for heroin detoxification.  The patient had withdrawal symptoms including nausea, body aches, fatigue, insomnia and anxiety.  The patient was using multiple bags per day of IV heroin with his last use the morning of admission.  The patient had multiple past detoxification treatments.  The patient was given a Methadone taper and was discharged.

The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders report that patients who fail to achieve abstinence, patients who relapse frequently, or fail to be cooperative with or benefit from outpatient detoxification, who currently abuse other substances, have very heavy use or tolerance putting one at high risk for complicated withdrawal, are candidates for inpatient detoxification treatment. 

According to the LOCADTR, the patient did require 24-hour treatment, as the patient could not safely and effectively be treated for detoxification in a less restrictive setting. The patient continued to use substances despite multiple past inpatient detoxification treatments, and the patient needed detoxification medication to modify withdrawal.  The patient was at risk for worsened withdrawal symptoms including severe withdrawal or overdose, due to the large amount of heroin use.  If not in this 24-hour setting the patient likely would have relapsed again, as evidenced by relapsing after past treatments.  The patient was reportedly homeless and did not have a sober support system, was unemployed and lacked coping skills.  It was unlikely that the patient would remain abstinent while having withdrawal symptoms, so the patient required time in this setting to stop withdrawal and decrease the chance that the patient would relapse again.  The patient had some continued withdrawal symptoms during his stay, including restlessness, anxiety, and irritable mood; his Methadone taper was continued. 

The medical necessity for inpatient detoxification admission is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major Depressive Disorder
 
Treatment: Inpatient mental health admission, medication, monitoring

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

This male was admitted to inpatient mental health treatment due to depressive symptoms including depressed mood, feelings of hopelessness, helplessness, guilt, worthlessness, decreased energy, repeating the same words, feeling stressed, withdrawn, having difficulty concentrating, and anxiety. He reported feeling pressure in his head. He scratched his arms 3 weeks prior to admission to relieve anxiety. He had no reported suicidal ideation, plan, intent, or behavior, or past suicide attempts. He felt responsible for his son's depression. He had a diagnosis of Major Depressive Disorder. 

The medical records provided did not provide enough specific evidence to support that he required only 24 hour acute psychiatric hospitalization or that he could not have been treated effectively in a less restrictive level of care. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorder reports that the least restrictive level of care for safe and effective treatment is appropriate. It also states that patients with suicidal intent or plan, or behaviors, or who present as an imminent danger to self or others are in need of hospital treatment. This patient did not have reports of suicidal ideation, plan, intent, behaviors, or past suicide attempts. There was no reported evidence that he was considered an imminent danger to self or others. 

There were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24 hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting.  There were no reports of hallucinations, delusional thinking, manic episodes, or acute medical instability.

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

This is a patient who is seeking growth hormone (GH) treatment under the indication of idiopathic short stature (ISS). He was born after term gestation and his birth weight was 5 pounds (lbs) 13 ounces (oz) and his birth length was 19 inches. His mother's height is 59 inches and father's height is 64 inches. He was initially evaluated in the pediatric endocrinology clinic and his height at that time was 117.2 centimeters (cm) (1.25 percentile (%tile): -2.24 standard deviations [SD]) while his weight was 22.6 kilograms [kg] (12%tile:-1.2 SD). His evaluation was unremarkable. The health plan's determination is overturned. As this patient is growing more than 2 SD below the mean for age and his growth velocity is poor, a trial of GH treatment is medically necessary. Overall this patient has grown 19.7 cm in 5.1 years which gives him a growth velocity of 3.9 cm per year which is less than expected and his height has dropped from -2.24 SD to -2.82 SD.
Appeal type: Medical necessity
Decision: Overturned

The patient was admitted following medical screening to inpatient level services for monitoring and detoxification and withdrawal management of severe alcohol, stimulant (cocaine), and opioid (heroin) use disorders.  The patient was using up to six bags of heroin daily with intranasal administration, large amounts of alcohol per day, and unspecified amounts of crack cocaine.  The patient had experienced moderately severe alcohol and opioid withdrawal symptoms at the time of admission with a positive drug screen that prompted her referral prior to entering court-mandated rehabilitation treatment.  The patient had failed to remain abstinent while participating in an outpatient substance use disorder treatment program that included medication assisted treatment.

The health plan's determination is overturned.  The Continued Inpatient Hospital Admission for Detoxification Services is medically necessary for this patient.  The patient in this case presented with a diagnosis of severe alcohol, opioid, and stimulant use disorders with history of relapse and use while receiving outpatient substance use disorder rehabilitation services.  The presenting clinical features and history and risk for withdrawal seizures and other complications of alcohol and opioid and stimulant use disorders did warrant the admission and continued inpatient level services with medical monitoring in this case scenario.  The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could not have been provided at a lower level of care in this case scenario.  Clinical records indicate a stormy clinical course requiring as needed (prn) medications, medication adjustments and ongoing interventions to address problematic behaviors with withdrawal management during the time interval under review.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented with vomiting and diarrhea for 3 days associated with decreased oral intake and decreased wet diapers. He had been having diarrhea non-bloody and 6-8 episodes per day leaking through his diaper. He also had 1 day of a cough. Reportedly, he has been refusing food and only drinking about 2 ounces (oz)/feed. He had positive sick contacts, with the babysitter and father developing vomiting and diarrhea. In the emergency room (ER), the patient was afebrile and the physical exam was notable for a mildly illness and dehydration but was otherwise normal. The health plan's determination is upheld.
This patient presented with vomiting and diarrhea. He did not have any abnormal vital signs. The most significant laboratory abnormality was a low bicarbonate level. He did not have an elevated blood urea nitrogen (BUN) or creatinine. The rest of his electrolytes were normal apart from a slightly abnormal chloride. At the time of admission, his exam was normal. There were no physical signs of dehydration on exam. He responded well to ER resuscitation of 2 normal saline boluses followed by 1.5 maintenance IVF. He rapidly improved and was discharged within 24 hours of his arrival.
Appeal type: Medical necessity
Decision: Overturned

The patient who was admitted following medical screening to acute inpatient level services for detoxification and withdrawal management of severe alcohol, stimulant (cocaine), and sedative-hypnotic-anxiolytic (benzodiazepine) use disorders. The patient was admitted to inpatient level care and placed on a detoxification regimen with a five-day Librium taper, vitamin replacement therapy, and medical monitoring. The health plan's determination is overturned. Yes, the requested health service/treatment of Medically Supervised Inpatient Detoxification, Withdrawal Management, and Stabilization Services,  date of service were  medically necessary for this patient. The presenting clinical features and history and risk for withdrawal seizures and other complications of alcohol/anxiolytic and stimulant use disorders did warrant the admission and continued inpatient level services with medical monitoring in this case scenario. The patient's continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could not have been provided at a lower level of care in this case scenario.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female who has osteoporosis. The provider is requesting Prolia, which is being denied by the patient's health plan as she has not tried and failed or had an adverse event (AE) to the preferred drug, intravenous (IV) Reclast. The reason cited as to why the patient cannot try IV Reclast is she is 'afraid of infusions'. She has tried by mouth (PO) alendronate, but it was stopped due to gastric distress, and no therapeutic benefit was observed.

The health plan's determination is upheld.

No, the requested treatment with Prolia (denosumab) is not medically necessary for this patient.

Prolia is a monoclonal antibody with affinity for nuclear factor-kappa ligand (RANKL). IV Reclast (zoledronic acid) is a bisphosphonate which inhibits bone resorption via actions on osteoclasts. Both are given to treat osteoporosis. According to UpToDate, "for patients with esophageal disorders, gastrointestinal intolerance, history of Roux-en-Y gastric bypass, or an inability to follow the dosing requirements of oral bisphosphonates, including an inability to sit upright for 30 to 60 minutes and/or to swallow a pill, we suggest IV bisphosphonates. We prefer IV zoledronic acid, which has been demonstrated to reduce vertebral and hip fractures. IV ibandronate is also available; however, there is no direct fracture prevention data for IV ibandronate. "Prolia" is an alternative to IV zoledronic acid for women at high risk for fracture." There are no head to head trials comparing the two drugs - Prolia and IV Reclast. There is some new data showing there is an increased risk of vertebral fracture after discontinuation of denosumab. 

In summary, there is no medical reason the patient cannot try IV Reclast. The fact that the patient is afraid of infusions does not constitute medical necessity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Plantar fasciitis
Treatment: Custom Shoe Inserts

Summary:
The patient is a female who complained of pain in both feet and that her feet felt "uneven".  The patient had been performing home physical therapy for three months and also tried using NSAIDs for pain also over three months with no resolution of pain.  The patient presented for orthotic consultation.  Three formed inserts were tried without any improvement. The patient suffers from plantar fasciitis, limb length discrepancy, and a cavus foot.  Custom orthotics was prescribed with 3 mm lift on the right side.

The patient has pain, a foot deformity, and has tried conservative care for greater than three months.  This included over-the-counter inserts, NSAIDs, and home therapy.  Surgical intervention is usually deferred until after custom orthotics has failed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Atrial fibrillation
Issue under review: Transcatheter closure of the left atrial appendage

Determination:
The health plan should cover the Transcatheter closure of the left atrial appendage.

This will decrease risk of CVA (cerebrovascular accident) compared to anticoagulation therapies.

Percutaneous closure with this device has been shown to have a clinical advantage in a narrow spectrum of patients, such as this case. It is not considered to be investigational for this clinical setting. The patient's CHAD (congestive heart failure, hypertension, age greater than or equal to 75, diabetes mellitus) score is actually higher with presence of embolic stroke, so anticoagulation is indicated. However, due to her history of intracerebral bleed and falls, she would be at high risk of a catastrophic event.

Community standards and CMS (Centers for Medicare and Medicaid Services) guidelines do allow for placement of this device in this clinical setting. LAA (left atrial appendage) closure for a patient who should be anticoagulated but who is at high risk of bleeding is an accepted indication.

Therefore, given the above, the Transcatheter closure of the left atrial appendage is recommended for approval.