External Appeals Searchable Archive

Database of closed NYS External Appeals that provides case summaries and appeal outcomes

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  • 0Overturned
  • 0Upheld
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Showing 1 to 10 of 21692
Summary References
Substance Abuse/ Addiction
Substance Abuse: Inpatient
United Healthcare Plan of New York
Overturned
Medical necessity
Male
40-49
2019
IPRO
201809-110342
201809-110342

  • Summary:

    Diagnosis: Substance Abuse Treatment: Admission for Inpatient Substance Rehabilitation Treatment The insurer denied the coverage. The denial was reversed. This male patient was admitted to inpatient substance rehabilitation treatment in mid-2018. He was reportedly using 1 bag of heroin per day and $25 of cannabis per day with last use on the day of admission. He was using heroin since age 25 and cannabis since age 16. He reportedly had family conflicts due to substance use, spent time with drug seeking behaviors, was unemployed, and unable to gain employment as a result. He reportedly could not maintain abstinence on his own and lacked insight into addiction. He reportedly had past inpatient substance detoxification treatment. He was homeless and was transferred to another inpatient substance rehabilitation treatment in mid-2018. The insurer denied coverage for inpatient substance rehabilitation treatment, as not medically necessary treatment. They stated that he did not have dangerous withdrawal, medical or mental health issues requiring 24 hour treatment, and they recommended a less restrictive level of care then. According to the LOCADTR he met criteria for substance residential treatment as he continued to use multiple substances despite treatment past inpatient substance treatment settings and he had positive toxicology for THC and opiates and lacked supports as he was homeless. The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but 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. Residential facilities provide a safe and substance-free environment in which residents learn individual and group living skills for preventing relapse. In this case the patient was considered in need of 24 hour residential treatment as he was discharged to another inpatient substance rehabilitation treatment. The patient lacked insight into their addiction and needed better coping skills, identification of relapse triggers, was unable to maintain abstinence on his own without this 24 hour therapeutic setting, needed more insight into addiction, was homeless and lacked supports for treatment as an outpatient.

  • Reference:

    1) The American Psychiatric Association Practice Guidelines for the Treatment of Patients with Substance Use
Blood Disorder
Home Health Care
Healthfirst Inc.
Upheld
Medical necessity
Male
70-79
2019
MCMC, LLC
201810-110716
201810-110716

  • Summary:

    Diagnosis: Diabetes mellitus, CHF, CVA Treatment: Personal Care Assistance, Level II 24 hours per day, seven days per week (split shift or live in). This patient with a history of Diabetes Mellitus, Congestive Heart Failure, Cerebrovascular Accident with residual left sided weakness, poor visual acuity and gait ataxia. Due to the severity of his multiple comorbid conditions, he requires assistance with the majority of his activities of daily living (ADLs). Although it is clear that this patient needs 24/7 assistance, his current needs actually require a higher level of care then what a Personal Care Aid/Home Health Aid can provide. Admission and long term residence in a skilled nursing facility is warranted, as the patient cannot be left alone. He requires safety supervision at all times. He is unable to self-direct his own care. He requires maximum assistance with transfers and requires two-person assistance. Furthermore, he requires total assistance with pouring and administering 15 medications up to four times a day. For these reasons, the proposed treatment of Personal Care Assistance, Level 11 24 hours per day, seven days per week (split shift or live in); for a total of 168 hours per week is not deemed medically necessary.

  • Reference:

    1) Sanford, Angela M., et al. "An international definition for nursing home." Journal of the American Medical Directors Association 16.3 (2015): 181-184. 2) Toles, Mark, et al. "Connect¿Home: Transitional Care of Skilled Nursing Facility Patients and their Caregivers." Journal of the American Geriatrics Society 65.10 (2017): 2322-2328.
Digestive System/ Gastrointestinal
Surgical Services
Excellus
Upheld
Medical necessity
Male
50-59
2019
IMEDECS
201810-111285
201810-111285

  • Summary:

    The patient has a past medical history significant for ulcerative colitis and past surgical history significant for ileoanal pouch who was seen for decreasing fecal latency. The progress note states the patient has minimal fecal incontinence with decreased fecal latency; symptoms have improved since starting cholestyramine. The use of the sacral nerve stimulator is under review. The health plan's determination is upheld. The sacral nerve stimulator is not indicated. The Sacral Neurostimulator is not indicated as the degree chronic fecal incontinence (e.g. greater than 2 episodes per week x 6 months) and failure of conservative therapies (e.g. loperamide, cholestyramine) are not documented in the medical records provided.

  • Reference:

    1) Paquette IM, Varma MG, Kaiser AM, Steele SR, Rafferty JF. The American Society of Colon and Rectal Surgeons' Clinical Practice Guideline for the Treatment of Fecal Incontinence. Dis Colon Rectum. 2015 Jul;58(7):623-36. 2) Thaha MA1, Abukar AA, Thin NN, Ramsanahie A, Knowles CH. Sacral nerve stimulation for faecal incontinence and constipation in adults. Cochrane Database Syst Rev. 2015 Aug 24;(8):CD004464. 3) Alavi K, Chan S, Wise P, Kaiser AM, Sudan R, Bordeianou L. Fecal Incontinence: Etiology, Diagnosis, and Management. J Gastrointest Surg. 2015 Oct;19(10):1910-21. Epub 2015 Aug 13. 4) McNevin MS, Moore M, Bax T. Outcomes associated with Interstim therapy for medically refractory fecal incontinence. Am J Surg. 2014 May;207(5):735-7; discussion 737-88.
Cardiac/ Circulatory Problems
Inpatient Hospital
Metroplus Health Plan
Upheld
Medical necessity
Female
60-69
2019
IMEDECS
201812-112688
201812-112688

  • Summary:

    This is a patient with a history of hypertension hyperlipidemia, presented to the emergency department with nausea, vomiting, and epigastric discomfort. Symptoms started 2 days prior to presentation, with reports of inability to keep food down and she had not had anything aside from water in 24 hours. The pain was described as constant, located in the epigastrium. There were no clear alleviating or exacerbating factors. The patient also experienced one episode of right arm pain, occurring 1 day prior to arrival as well. The health plan's determination of medical necessity is upheld.The requested health service/treatment of inpatient hospitalization for the above date is not medically necessary for this patient. This is a nonspecific chest pain rule out presentation. The patient had EKG changes, which per the emergency department were chronic and unchanged from previous EKGs. The patient had negative cardiac enzymes and no evidence of ST elevation.

  • Reference:

    1) Chase M, Robey JL, Zogby KE, et al. Prospective validation of the Thrombolysis in Myocardial Infarction Risk Score in the emergency department chest pain population. Ann Emerg Med 2006; 48:252. 2) Lee B, Chang AM, Matsuura AC, et al. Comparison of cardiac risk scores in ED patients with potential acute coronary syndrome. Crit Pathw Cardiol 2011; 10:64. 3) Hess EP, Agarwal D, Chandra S, et al. Diagnostic accuracy of the TIMI risk score in patients with chest pain in the emergency department: a meta-analysis. CMAJ 2010; 182:1039. 4.Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J 2008; 16:191. 5. Backus BE, Six AJ, Kelder JC, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol 2013; 168:2153.
Substance Abuse/ Addiction
Substance Abuse: Inpatient
Fidelis Care New York
Upheld
Medical necessity
Female
40-49
2019
IMEDECS
201902-113919
201902-113919

  • Summary:

    The patient is a female with substance use disorders who was admitted to an inpatient detoxification unit for 6 days. The patient presented requesting treatment of multiple substance use disorders. The patient reported she was using two bags of heroin intravenously daily for about 10 weeks. Before that the patient was using her husband's prescription opiate (Dilaudid). She was also using cannabis and cocaine regularly. The patient reported the following symptoms: yawning, hot/cold sweats, joint pain, and rhinorrhea. The initial evaluation by the nurse practitioner stated, the patient appeared "with withdrawals" but no specifics are given on physical examination. Her Clinical Opiate Withdrawal Scale (COWS) score was 12 which is consistent with mild withdrawal. The COWS was repeated and was 14 consistent with moderate withdrawal (cutoff for moderate = 13). The patient's blood alcohol level was negative. Her urine was positive for opiates, cocaine and tetrahydrocannabinol (THC). The patient denied any psychiatric symptoms including suicidal ideation. The patient was previously approved 2 days. The health plan's determination is upheld. She was not using any substances that are associated directly with the possibility of life-threatening withdrawal. She had no diagnosed psychiatric comorbidity. She had no significant physical health conditions. She reported that she had stable and safe housing with a supportive significant other who did not use drugs. There were no COWS assessments during this time period under review and no notes from physicians or nurse practitioners. There were no notes that documented the medical decision making for continued inpatient stay. Using this information and the level of care for alcohol and drug treatment referral (LOCADTR) continuation of stay instrument was used; it resulted in the finding that the patient did not meet criteria for inpatient detoxification.

  • Reference:

    1) Harwell, K & Brady, K (2018). Determining appropriate levels of care for treatment of substance use disorders. In R. Saitz (ed.), UpToDate. Retrieved on 7/7/19 from UpToDate.com 2) American Psychiatric Association (APA). Practice guideline for the treatment of patients with substance use disorders, 2nd ed. 2006. p90-100. Retrieved on 7/9/18 from https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/substanceuse.pdf 3) Sevarino, K. (2019). Opioid withdrawal in adults: Clinical manifestations, course, assessment, and diagnosis. In A. Saxon (ed.), UpToDate. Retrieved on 7/7/19 from UpToDate.com 4) LOCADTR criteria.
Substance Abuse/ Addiction
Inpatient Rehabilitation
Fidelis Care New York
Upheld
Medical necessity
Male
50-59
2019
IMEDECS
201902-114093
201902-114093

  • Summary:

    The patient entered treatment for problems with alcohol and marijuana use. The patient stated that the use of these substances had impacted the patient's ability to work. A positive urine drug screen for marijuana put the job in jeopardy. This admission was the patient's first episode of treatment for substance use disorders. Initial urine drug screen was positive for cannabis. Blood-alcohol level was zero. The health plan's determination is upheld. The Inpatient Rehabilitation Services are not medically necessary for this patient. The patient could have been cared for at a lower level of care. He did not have serious psychiatric symptoms that needed to be managed in an inpatient rehabilitation setting to be effective. The patient had used alcohol in settings that could be hazardous to others. The patient did not need to be managed in inpatient rehab in order to safely address cognitive or behavioral impairment.

  • Reference:

    1) Dugosh KL, Cacciola JS, Saxon AJ. Clinical assessment of substance use disorders. UpToDate. Retrieved February. 2018. 2) Hartwell K, Brady K. Determining appropriate levels of care for treatment of substance use disorders. UpToDate Inc., Waltham, MA. Last reviewed January. 2016. 3) Stallvik M, Gastfriend DR, Nordahl HM. Matching patients with substance use disorder to optimal level of care with the ASAM criteria software. Journal of Substance Use. 2015 Nov 2;20(6):389-98.
Substance Abuse/ Addiction
Substance Abuse: Inpatient
United Healthcare Plan of New York
Overturned
Medical necessity
Male
30-39
2019
IPRO
201902-114307
201902-114307

  • Summary:

    Diagnosis: Substance Abuse Treatment: Inpatient Admission for Substance Rehabilitation Treatment The insurer denied the coverage. The denial was reversed. This patient is a male was admitted to this inpatient substance rehabilitation treatment for substance rehabilitation treatment. He was using cocaine and cannabis and had a positive toxicology for tetrahydrocannabinol (THC) and cocaine. He was mandated to treatment by his parole officer. His longest reported period of abstinence was lasted for a few years when he was incarcerated. He had past inpatient substance rehabilitation treatments in mid-2018 and late 2018. He was in outpatient substance treatment and had a positive toxicology for THC and cocaine. He lived with family and attended group and individual therapy and was discharged in late 2018. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he met criteria for substance residential treatment as he continued to use multiple substances despite past inpatient residential treatment settings and outpatient substance treatment. He was in outpatient substance treatment and had a positive toxicology for THC and cocaine. The patient had legal issues and was mandated to treatment by his parole officer. He was unable to stop substance use without being in this sober and supervised therapeutic residential inpatient setting. Without this structured and supervised therapeutic residential treatment, he likely would have quickly relapsed.

  • Reference:

    1) The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders 2) LOCADTR
Orthopedic/ Musculoskeletal, Skin Disorders
Pharmacy/ Prescription Drugs
Fidelis Care New York
Upheld
Medical necessity
Female
50-59
2019
IPRO
201902-114344
201902-114344

  • Summary:

    Diagnosis: Psoriasis and Psoriatic Arthritis Treatment: Pharmacy/Prescription Drugs Summary: This patient with psoriasis and PsA (psoriatic arthritis) has mechanical knee pain and inflammatory back pain. There is no synovitis and some clearing of skin lesions of the left elbow and knees is noted. Osteoarthritis of multiple sites and psoriasis is noted. A history of hair loss with methotrexate (MTX) is noted. The plan is for Humira at psoriasis dosing. The prior approval form indicates that the request is for the treatment of psoriasis. There is no indication that the patient has gotten Humira yet. In a letter accompanying the appeal request the MD notes that the patient has ongoing PsA and that weekly Humira can be used when the patient is not on MTX. The insurer has denied coverage for Humira Pen 40mg/0.4ml SC PNKT. The denial was upheld. Humira treats both psoriasis and PsA. The FDA-labeling for Humira indicates one vial SQ every other week for PsA. This can be increased to every week if needed, if the patient is not on MTX. The dosing for psoriasis is 80 mg followed by one vial SQ every other week. The documentation in this case is inconsistent. The office note and Prior Approval request indicate that the Humira is for the psoriasis, but the medical doctor (MD) appeal letter notes it is needed for PsA. If the request is for the use of Humira in the treatment of psoriasis then the insurer is correct in denying every week as the indication is for every other week. If in fact the request is for the treatment of PsA then the insurer's denial is still valid, as there has not been any trial of the every other week dosing. The weekly dosing is used if every other week fails. No synovitis is noted at the office visit, and there is no documentation that supports the need to bypass the standard every other week dosing and going straight to every week. Humira Pen 40mg/0.4ml SC PNKT once weekly is not considered medically necessary for this patient. As noted above, the every other week dosing is appropriate. The patient's clinical condition does not meet national criteria for weekly dosing of Humira Pen 40mg/0.4ml SC PNKT. Every week is not indicated for psoriasis, and there has been no trial of the standard every other week for PsA.

  • Reference:

    1) https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/125057s410lbl.pdfle 2) Adalimumab: drug information.Lexicomp https://www.uptodate.com/contents/adalimumab-including-biosimilars-of-adalimumab-drug-
Orthopedic/ Musculoskeletal
Inpatient Hospital
Healthfirst Inc.
Upheld
Medical necessity
Female
60-69
2019
IPRO
201902-114385
201902-114385

  • Summary:

    Diagnosis: Hip pain Treatment: Inpatient admission, medication, monitoring The insurer denied the inpatient admission. The denial was upheld. Patient was brought in by ambulance to the Emergency Department (ED) with severe left hip pain and could not walk. Past medical history was significant for spinal stenosis and chronic hip pain. She was admitted to the hospital and provided with a Lidocaine patch and Flexeril. Imaging did not demonstrate a fracture. She was evaluated by physical therapy (PT) who recommended rehabilitation. She was discharged and provided with Celebrex. The hospital record demonstrated improvement after prescription pain medication was provided. The physical examination reported full range of motion to the left hip, but with pain. Consultations did not recommend additional testing, invasive management or parenteral medications. Her vital signs were stable. She was able to tolerate oral medications. She did not require treatment for underlying co-morbidities. All services could have been provided in the ED or in an outpatient setting. There were no extenuating circumstances to warrant the level of service provided (admission).

  • Reference:

    1) MCG 23rd Edition for Acute Hospitalization/Musculoskeletal
Substance Abuse/ Addiction
Substance Abuse: Inpatient
United Healthcare Plan of New York
Overturned
Medical necessity
Male
20-29
2019
IPRO
201902-114419
201902-114419

  • Summary:

    Diagnosis: Alcohol dependence and substance abuse Treatment: Rehab for alcohol dependence The insurer has denied inpatient admission. That denial was reversed. This male patient was admitted to inpatient substance rehabilitation treatment as he reportedly was drinking 1 gallon of whiskey 1-2 times per week, smoking a blunt of cannabis daily, using 30 mg of Percocet 1-2 times per week, and could not maintain abstinence. It was reported that the patient was discharged after threatening violence towards a staff member. It also was reported that he was picking and scratching his head. He refused aftercare referrals. The American Psychiatric Association (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 he was using multiple substances; including alcohol, opiates, and cannabis. According to the LOCADTR, he met criteria for inpatient substance rehabilitation treatment as he continued to use multiple substances despite past inpatient treatments. It was reported that he was increasing frequency and amount of use. He was unable to stop substance and alcohol use without being in a sober and supervised therapeutic inpatient residential setting. Without this structured and supervised therapeutic residential treatment he likely would have relapsed quickly. Based on the above, the medical necessity for the inpatient hospital stay is substantiated.

  • Reference:

    1) The American Psychiatric Association Practice Guidelines for the Treatment of Patients with Substance Use Disorders