External Appeals Searchable Archive

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

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Showing 1 to 10 of 13599
Summary References
Digestive System/ Gastrointestinal
Inpatient Hospital
Fidelis Care New York
Overturned
Medical necessity
Male
0-9
2021
MCMC, LLC
202105-137833
  • Summary:

    Diagnosis: Multiple Episodes Of Vomiting With Belly Pain. Treatment: Inpatient admission. The insurer denied the inpatient admission. The denial is overturned. The patient is a male child with medical history significant for febrile seizures. He presented to the ED (emergency department) with three-day history of recurrent vomiting (about ten episodes daily) and poor oral intake with decreased urine output. He had no fevers and no diarrhea, but his mother reported some epigastric abdominal pain with emesis. The pediatrician prescribed Zofran, but the child was unable to tolerate it. The patient's vital signs included temperature 37.5, heart rate 140, blood pressure 95/77, and respiratory rate 22. Examination was significant for no acute distress, tired dehydrated appearance, dry mucous membranes, tachycardia, clear lungs, non-tender abdomen with no guarding or rebound, good perfusion, and non-focal neurologic exam. Laboratory evaluation revealed venous pH (potential of hydrogen) 7.28 with venous bicarbonate 13, CO2 (carbon dioxide) 10, urinalysis with specific gravity greater than 1.030, and ketonuria. His bedside glucose was 45. The patient's glucose was treated with D10 (10% dextrose) bolus. He was also treated with two IV (intravenous) fluid boluses and Zofran prior to admission for further management. Admission orders included IV (intravenous) fluids, Zofran as needed, strict ins/outs, vital signs every four hours, repeat metabolic pane, and oral intake as tolerated. Repeat blood work the next day noted improvement in CO2 (carbon dioxide) to 17 with normal glucose 82. He remained hemodynamically stable, able to tolerate food and fluids sufficiently to discharge home. Yes, the Inpatient admission was medically necessary and appropriate. Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children. There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of five years. Most cases are caused by viruses, are self-limited, and require supportive treatment. According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Vomiting limits the success of oral rehydration, prompting use of anti-emetic medications. Hospitalization may be necessary for those that do not respond to oral hydration and anti-emetic treatment, as well as those with severe dehydration. This young male child presented to the ED (emergency department) with significant dehydration from refractory vomiting over the course of three days, with dry mucous membranes, decreased urine output, and decreased activity. Laboratory evaluation revealed severe hypoglycemia and significant metabolic acidosis. He was treated appropriately in the ED (emergency department) with parenteral fluids and dextrose, admitted because of the severity of his dehydration and concern for further vomiting and metabolic decompensation. While he remained hemodynamically stable and was able to advance his diet without ongoing vomiting, the level of care that he received was most consistent with acute inpatient management, despite the brevity of his hospital stay.
  • Reference:

    1) AKC Leung, DL Sigalet. Acute abdominal pain in children. American Family Physician 2003; 67(11):2321-2326. 2) TM Shields, JR Lightdale. Vomiting in children. Pediatr Rev 2018; 39(7):342-358. 3) G Santillanes, E Rose. Evaluation and management of dehydration in children. Emerg Med Clin North Am 2018; 36(2):259-273. 4) K Brady. Acute gastroenteritis: Evidence-based management of pediatric patients. Pediatr Emerg Med Pract 2018; 15(2):1-25.
Cardiac/ Circulatory Problems
Inpatient Hospital
Affinity Health Plan
Overturned
Medical necessity
Female
60-69
2021
MCMC, LLC
202105-138071
  • Summary:

    Diagnosis: Chest pain. Treatment: Inpatient admission. The insurer denied the inpatient admission. The denial is overturned. The patient is a female. She has a past medical history significant for HTN (hypertension), GERD (gastroesophageal reflux disease), back pain, psoriasis, dyslipidemia, CAD (coronary artery disease), status post PCI (percutaneous coronary intervention) of LAD (left anterior descending artery). She presented to the ER (emergency room) with complaints of new onset chest pain, pressure like, radiating to the left arm, associated with dyspnea, relieved by nitroglycerin. The patient was admitted for suspected unstable angina. The patient was hemodynamically stable. ECG (electrocardiogram) revealed no acute ischemic changes. The patient was referred for cardiac catheterization, and was found to have non-obstructive CAD (coronary artery disease), which was managed medically. Echocardiogram was performed and revealed normal LV (left ventricle) systolic function. She was discharged home with a plan for outpatient follow-up. Yes, the Inpatient admission was medically necessary. The patient presented with new onset chest pain, with features suggestive of unstable angina. The patient had multiple risk factors for CAD (coronary artery disease), as well as a known history of coronary artery disease, including a history of prior percutaneous revascularization with stent placement. There was a high index of suspicion for an ACS (acute coronary syndrome), and a cardiac catheterization was performed. Given the presentation, risk factors, as well as clinical suspicion for an acute coronary syndrome/unstable angina, she would not be an appropriate candidate for an ED (emergency department) 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 Inpatient admission was medically necessary in this clinical setting.
  • Reference:

    1) Harrison's Principles of Internal Medicine, 20th Edition. J. Larry Jameson, Anthony S. Fauci, Dennis L. Kasper, Stephen L. Hauser, Dan L. Longo, Joseph Loscalzo. 2) CURRENT Medical Diagnosis and Treatment 2019, 58th Edition (LANGE CURRENT Series) by Stephen J. McPhee and Maxine Papadakis. 3) Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, Single Volume (Heart Disease (Braunwald) (Single Vol)) 11th Edition by Peter Libby MD, Robert O. Bonow MD, Douglas L. Mann MD FACC, and Douglas P. Zipes MD. 4) 2014 AHA/ACC Guideline for the Management of Patients With NonST-Elevation Acute Coronary Syndromes A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Ezra A. Amsterdam, Nanette K. Wenger, Ralph G. Brindis, Donald E. Casey Jr., Theodore G. Ganiats, David R. Holmes Jr., Allan S. Jaffe, Hani Jneid, Rosemary F. Kelly, Michael C. Kontos, Glenn N. Levine, Philip R. Liebson, Debabrata Mukherjee, Eric D. Peterson, Marc S. Sabatine, Richard W. Smalling and Susan J. Zieman Journal of the American College of Cardiology Volume 64, Issue 24, December 2014. 5) Care of the Patient with Chest Pain in the Observation Unit. Borawski JB, Graff LG, Limkakeng AT. Emerg Med Clin North Am. 2017 Aug;35(3):535-547. 6) Alternative Strategies to Inpatient Hospitalization for Acute Medical Conditions: A Systematic Review. Conley J, O'Brien CW, Leff BA, Bolen S, Zulman D. JAMA Intern Med. 2016 Nov 1;176(11):1693-1702.
Genetic Diseases
Pharmacy/ Prescription Drugs
Healthfirst Inc.
Upheld
Medical necessity
Female
10-19
2021
MCMC, LLC
202106-139124
  • Summary:

    Diagnosis: VLCAD (very long chain acyl-Coenzyme A dehydrogenase) deficiency Treatment: Dojolvi SGM The insurer denied the Dojolvi SGM The denial is upheld. The patient is a girl with a diagnosis of very long chain acyl-Coenzyme A dehydrogenase (VLCAD) deficiency. She has frequent episodes of vomiting and headache and was recently diagnosed with cyclic vomiting syndrome. She did have episodes of mild hypoglycemia when younger. She is now clinically stable with respect to her VLCAD (very long chain acyl-Coenzyme A dehydrogenase) without rhabdomyolysis or myoglobinuria, although she does have muscle pains, and is treated with medium chain triglyceride oil and betaquik. However, she is variably or not compliant with carnitine or MCT (mediumchain triglyceride) Oil supplements. Plasma carnitine levels are normal. Other medical problems include abdominal pain, adjustment disorder with anxious mood, ADHD (attention deficit hyperactivity disorder), chromosomal abnormalities of chromosome 7 and 16, excessive sweating, fatigue, constipation, gait difficulty, hyperhidrosis, learning disability, scoliosis, self-injurious behavior, and urinary retention. She does not have cardiomyopathy. Molecular genetic testing demonstrated one pathogenic variant and one variant of uncertain significance in the VLCAD (very long chain acyl-Coenzyme A dehydrogenase) gene. The patient's provider has requested Dojolvi, an alternative to medium chain triglycerides, as a dietary supplement in her to hopefully improve her compliance with dietary management of her VLCAD (very long chain acyl-Coenzyme A dehydrogenase), and her general clinical state and prevent episodes of hypoglycemia and/or rhabdomyolysis. No, the requested Dojolvi is not medically necessary. While Dojolvi is the only FDA (United States Food and Drug Administration)-approved dietary supplement for VLCAD (very long chain acyl-Coenzyme A dehydrogenase), it is not necessary for all patients with this disorder of long chain fatty acid oxidation. This young woman does not have active current rhabdomyolysis, muscle disease directly caused by deficiency of this enzyme of long chain fatty acid oxidation, hypoglycemia, or cardiomyopathy. Therefore, given the mild to moderate clinical presentation of her disease, replacement of medium chain triglyceride supplements with Doljovi is not medically necessary, clinically appropriate, and is not supported by the current treatment guidelines for VLCAD (very long chain acyl-Coenzyme A dehydrogenase) patients with mild to moderate disease. Given that this individual has only mild to moderate VLCAD (very long chain acyl-Coenzyme A dehydrogenase) deficiency that is largely asymptomatic and well-controlled on MCT (mediumchain triglyceride) supplements, Dojolvi supplementation is not medically necessary or clinically appropriate in her specific clinical context. As such, health plan acted reasonably with sound medical judgment and in the best interest of the patient in this specific clinical context and scenario.
  • Reference:

    1) Management and diagnosis of mitochondrial fatty acid oxidation disorders: focus on very-long-chain acyl-CoA dehydrogenase deficiency. Yamada K, Taketani T. J Hum Genet. 2019 Feb;64(2):73-85. 2) Triheptanoin: First Approval. Shirley M. Drugs. 2020 Oct;80(15):1595-1600. 3) Triheptanoin versus trioctanoin for long-chain fatty acid oxidation disorders: a double blinded, randomized controlled trial. Gillingham MB, Heitner SB, Martin J, Rose S, Goldstein A, El-Gharbawy AH, Deward S, Lasarev MR, Pollaro J, DeLany JP, Burchill LJ, Goodpaster B, Shoemaker J, Matern D, Harding CO, Vockley J. J Inherit Metab Dis. 2017 Nov;40(6):831-843.
Dental Problems
Dental/ Orthodontic Procedure
Guardian Life Ins. Co.
Overturned
Medical necessity
Female
30-39
2021
MCMC, LLC
202106-139302
  • Summary:

    Diagnosis: Tooth fracture. Treatment: D2954 tooth #14; D2750 tooth #14. The insurer denied the D2954 tooth #14; D2750 tooth #14. The denial is overturned. The patient is a female requesting dental benefits on tooth #14 (D2954 - prefabricated post and core; D2750 - crown). The patient presented with bleeding and swollen gums. The patient presented with fracture to tooth #14; she stated she was experiencing pain upon chewing/biting down. Tooth #14 already had a large amalgam filling covering approximately 85 percent of the occlusal surface. X-rays, photos, and clinical consultation were performed. The Health plan denied the crown due to no decay or injury present on tooth #14. The provider appealed the claim based on the condition of tooth #14. Yes, the proposed treatment of a prefabricated post and core and crown on tooth #14 was medically necessary. Due to the very large existing filling and the area of fracture on the lingual aspect of tooth #14, a prefabricated post and core and crown is the standard of care to prevent the tooth from further fracture and restore function and comfort to this patient. No, the health plan did not act reasonably with sound medical judgement and in the best interest of the patient as the prefabricated post and core and crown on tooth #14 was medically necessary. Given the condition of tooth #14 and the patients symptoms, if left untreated, this would only lead to further fracture and may eventually lead to tooth loss. The tooth may further fracture in a manner such that it becomes non-restorable and would need to be extracted.
  • Reference:

    1) Contemporary Fixed Prosthodontics--4thed by Stephen Rosenstiel, Martin Land, Junhei Fujimoto. (Mosby 2006).
Cardiac/ Circulatory Problems
Inpatient Hospital
Healthfirst Inc.
Upheld
Medical necessity
Male
60-69
2021
MCMC, LLC
202107-139589
  • Summary:

    Diagnosis: Ischemic systolic heart failure with reducedejection fraction (40-45%), hypertension (HTN), and atrial fibrillation. Treatment: Inpatient admission. The insurer denied the inpatient admission. The denial is upheld. The patient is a male with a history of ischemic systolic heart failure with reduced ejection fraction (40-45%), hypertension (HTN), and atrial fibrillation. He presented to the hospital for an elective catheter ablation of atrial fibrillation and atrial flutter. He underwent uncomplicated pulmonary vein isolation and cavotricuspid isthmus atrial flutter ablation and was discharged home the following day. No, inpatient hospital admission following uncomplicated ablation of atrial fibrillation and atrial flutter is not medically necessary. This patient presented to the hospital for an elective electrophysiological study and ablation. According to hospital records, the ablation was successfully performed without complication. Observation following ablation was unremarkable and no post operative issues were noted. The patient was discharged home the following day. In this case, there were no clinical reasons for hospital admission and the patient could safely be managed at a lower level of care. In two multicenter registry studies looking at healthcare utilization after electrophysiological study catheter ablation, more than 80% of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity. (Reference 1) Another study demonstrated that patients undergoing atrial fibrillation ablation procedures could be safely discharged on the same day. (Reference 2) The current standard of care in an uncomplicated atrial fibrillation ablation is to manage patients at a lower level of care.
  • Reference:

    1) Biviano AB et. al. Healthcare Utilization and Quality of Life Improvement after Ablation for Paroxysmal AF in Younger and Older Patients. Pacing Clin Electrophysiol. 2017 Apr;40(4):391-400. 2) Bartoletti S et al. Same-day discharge in selected patients undergoing atrial fibrillation ablation. Pacing Clin Electrophysiol. 2019 Nov;42(11):1448-1455.
Endocrine/ Metabolic/ Nutritional
Inpatient Hospital
HIP Health Plan of New York
Overturned
Medical necessity
Male
60-69
2021
MCMC, LLC
202107-139608
  • Summary:

    Diagnosis: Hematuria and abdominal pain Treatment: Inpatient admission The insurer denied the inpatient admission The denial is overturned. The patient is a male without significant past medical history who was admitted with hematuria and abdominal pain. Computed tomography of the abdomen/pelvis demonstrated mild to moderate bilateral hydroureteronephrosis and bilateral perinephric stranding. The patient was afebrile with a blood pressure 173/95 pulse 94. Labs were notable for white blood cell count 20,800, glucose 188, potassium 5.1, bicarbonate 19, BUN (blood urea nitrogen) 146, and creatinine 7.1. The urinalysis was positive for leukocyte esterase, bacteria, and white blood cells. Intravenous fluids intravenous antibiotics were provided. A Foley catheter was placed. Serial glucose levels were followed and sliding scale insulin was administered. The creatinine on follow-up was 3.0, 2.3, 1.7, and 2.6. Amlodipine and glipizide were initiated. The urine culture was negative. The patient was discharged on tamsulosin and finasteride. The member had severe acute kidney injury on admission with a BUN 146 and creatinine 7.1, with no preceding history of chronic kidney disease. This was accompanied by hyperkalemia and metabolic acidosis. Renal function improved initially with the creatinine dropped to 1.7 mg/dL but subsequently worsened with a rise in creatinine to 2.6. The member additionally was newly diagnosed with diabetes, indicating he was in immunocompromised state. He had bilateral pyelonephritis noted on computed tomography of the abdomen/pelvis with evidence of urinary obstruction on admission, and with a significant degree of leukocytosis. Intravenous antibiotics and intravenous fluids were required. In summary, inpatient admission was medically necessary.
  • Reference:

    1) Harrison's Principles of Internal Medicine, 20th edition 2) MCG (Milliman Care Guidelines), 24th edition, ORG M-326, Renal Failure, Acute 3) MCG (Milliman Care Guidelines), 24th edition, ORG M-300, Urinary Tract Infection
Dental Problems
Dental/ Orthodontic Procedure
Healthfirst Inc.
Overturned
Medical necessity
Male
10-19
2021
MCMC, LLC
202107-139611
  • Summary:

    Diagnosis: Deep impinging overbite Treatment: D8080 Comprehensive Orthodontic Treatment of the Adolescent Dentition, Pre-service The insurer denied the D8080 Comprehensive Orthodontic Treatment of the Adolescent Dentition, Pre-service The denial is overturned. The patient is a male. The request is for dental benefits for orthodontic treatment (braces). Orthodontic records were created including x-rays and photos. The patient's clinical exam reveals mild spacing, slight protrusion of upper teeth, deep impinging overbite with tissue damage. The Health plan denied the treatment because the patient did not score a 26 on the Handicapping Labio-Lingual Deviation (HLD) Index. The provider appealed because the patient presents with a deep impinging overbite with tissue damage- - an automatic qualifier for orthodontic therapy on the Handicapping Labio-Lingual Deviation (HLD) index. Yes, the proposed treatment of orthodontic therapy (braces) is medically necessary. As evident on the photos, the patient has a deep impinging over-bite of almost 100 percent with damage to the gums on the upper anterior palate. The imprint of the lower incisors are visible within the folds of the rugae present on the upper palate; this shows the impact to the area. The extent of the over-bite is significant; if left untreated, it will continue to cause damage to the upper gum tissue as well as discomfort to the patient. This will adversely affect the patient's ability to have optimal chewing function as well as difficulty with speech. Long term, the patient may experience gum recession, strained facial muscles and ultimately jaw pain.
  • Reference:

    1) Evidenced Based Orthodontics -2nd ed by Greg J. Huang, Stephen Richmond, Katherine W.L. Vig (Wiley--2018). 2) Orthodontic Biomechanics: treatment of Complex Cases using clear Aligners by Tareh El-Bialy, Donna, Galante, Sam Daher ( Benthan Science-2016). 3) "Handicapping Labio-Lingual Deviation (HLD) Index Report ; effective 09/01/2012.
Dental Problems
Dental/ Orthodontic Procedure
Healthfirst Inc.
Overturned
Medical necessity
Female
50-59
2021
MCMC, LLC
202107-139621
  • Summary:

    Diagnosis: Tooth decay. Treatment: D2791--All Metal Crown (Tooth #30, #31); D3330--Nerve Treatment on Molar Tooth (Tooth #30, #31). The insurer denied the D2791--All Metal Crown (Tooth #30, #31); D3330--Nerve Treatment on Molar Tooth (Tooth #30, #31). The denial is overturned. The patient is a female requesting root canal therapy and crowns on teeth #30 and #31. The patient has severe decay into both nerves and will need crowns to restore both teeth. Yes, the proposed metal crowns (D2791) on teeth #30 and #31 and nerve treatment of a molar tooth (D3330) on teeth #30 and #31 are medically necessary. Teeth #30 and #31 are functioning teeth and need the treatments described (root canals and crowns). The denial is based upon the need to keep (i.e., treat) any abutment teeth for bridges or partial dentures, both of which the patient does not have or need. However, the patient has severe tooth decay extending into the nerves of these teeth. These two teeth are fully functional and with the treatments described, will remain fully functional for many years. It is within the standard of care to restore functional teeth. The treatments requested, root canals and crowns, are medically necessary.
  • Reference:

    1) Contemporary Fixed Prosthodontics by Stephen F. Rosenstiel, BDS, MSD and Martin F. Land, DDS, MSD. Elsevier 2016.
Digestive System/ Gastrointestinal
Inpatient Hospital
Affinity Health Plan
Upheld
Medical necessity
Female
30-39
2021
MCMC, LLC
202107-139625
  • Summary:

    Diagnosis: Vomiting Treatment: Inpatient admission The insurer denied the inpatient admission. The denial is upheld. The patient was a female patient who had presented to the ED (emergency department) of the facility filing the appeal for the presenting complaints of emesis and diarrhea. The patient has the diagnosis of DM1 (diabetes mellitus type 1). The patient has no prior history of DKA (diabetic ketoacidosis). The patient also has a history of gastroparesis. The patient reported that the diarrhea was non-bloody. The patient also reported that the many episodes of emesis were non-bloody. The last glucose was 256 on the patient's continual glucose monitoring device. There were no fevers reported. A urine dip for ketones was positive prior to arrival. The patient denied fever, chills, chest pain, shortness of breath, dysuria, headache, dizziness, or any tingling as per the provided record. A venous blood gas had a pH (power of hydrogen) of 7.461. The patient had an anion gap of 19. The lactic acid was 2.4. The betahydroxybutyrate was elevated at 3.60. The highest blood sugar in the ED (emergency department) was documented at 265. The BUN (blood urea nitrogen) was 22 and the creatinine was 0.97. The admitting diagnosis was diabetic gastroparesis. No, inpatient hospital admission was not medically necessary. While the treatment provided was medically appropriate, the care was not rendered at a level at which was medically necessary. The request for authorization of the hospital admission was not medically necessary. The clinical information sent shows that the patient was evaluated in the emergency room for high blood sugar. There was no documentation of high blood sugar with acid in the blood, very high blood sugar with confusion, significant dehydration (loss of body fluid), vomiting that would not stop despite treatment, unexplained fever or severe infection. Despite the patient's presentation the care as provided could have been rendered in its entirety at a lower level of care. The patient has diabetic gastroparesis with episodes of emesis. However, the patient did not show evidence of a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. The patient showed no evidence of dehydration on laboratory studies. The patient had improved with treatment delivered in the ED (emergency department). As such, the care could have been rendered at a lesser level.
  • Reference:

    1) Koch KL. Gastric neuromuscular function and neuromuscular disorders. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 11th ed. Philadelphia, PA: Elsevier; 2021:chap 50. 2) Bharucha AE, Kudva YC, Prichard DO. Diabetic Gastroparesis. Endocr Rev. 2019 Oct 1;40(5):1318-1352. doi: 10.1210/er.2018-00161. PMID: 31081877; PMCID: PMC6736218. 3) Aswath GS, Foris LA, Ashwath AK, Patel K. Diabetic Gastroparesis. 2021 Apr 3. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. PMID: 28613545.
Dental Problems
Dental/ Orthodontic Procedure
Empire BlueCross BlueShield HealthPlus
Overturned
Medical necessity
Female
10-19
2021
MCMC, LLC
202107-139631
  • Summary:

    Diagnosis: Crossbite. Treatment: Braces (Comprehensive Orthodontic Treatment) (Pre-Service). The insurer denied the Braces (Comprehensive Orthodontic Treatment). The denial is overturned. The patient is a female requesting orthodontic benefits. She has a class III skeletal occlusion. The lower lateral incisors are in crossbite. Yes, the proposed braces are medically necessary. The patient has both lower lateral incisors (teeth #23 and #26) in anterior crossbite. This means the lower teeth are outside of the upper teeth, which is backwards. This will, over time, contribute to trauma and/or breakage of teeth because the teeth are meshing incorrectly. This condition can also contribute to future temporomandibular problems (i.e., pain) because it places extra pressure on the temporomandibular joints and can cause premature breakdown. Orthodontic treatment is needed to correct the crossbite. There is gingival recession (gum loss) present. This is an automatic qualifier for treatment according to the handicapping index scale.
  • Reference:

    1) Contemporary Orthodontics by William R. Proffit DDS PhD, Henry W. Fields Jr. DDS MS MSD, et al. Elsevier 2018. 2) Handicapping Labio-Lingual Deviation (HLD) Index Report; effective 09/01/2012.