External Appeals Searchable Archive

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

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  • 0Overturned
  • 0Upheld
  • 0Overturned in Part
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Showing 1 to 10 of 8329
Summary References
Infectious Disease
Inpatient Hospital
Healthfirst Inc.
Upheld
Medical necessity
Male
0-9
2019
IMEDECS
201904-115664
201904-115664

  • Summary:

    The patient presented with swelling to the dorsum of the left hand after a fall/bug bite . The patient was admitted for antibiotic treatment. The patient was treated with intravenous (IV) antibiotics for presumed cellulitis and admitted for antibiotic management and to rule out deep tissue infection. Consults were completed. A deep tissue infection was ruled out. The health plan has denied the inpatient stay as not medically necessary. The health plan's determination was upheld. Therefore the inpatient hospital stay was not medically necessary.

  • Reference:

    1) Halilovic J, Heintz B, Brown J. Risk factors for clinical failure in patients hospitalized with cellulitis and cutaneous abscess. The Journal of Infection. 2012;65(2):128. 2) Stevens D, Bisno A, Chambers H, Dellinger E. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clinical Infectious Diseases. 2014;59(2):147.
Respiratory System
Inpatient Hospital
MVP Health Plan
Upheld
Medical necessity
Female
0-9
2019
MCMC, LLC
201904-115695
201904-115695

  • Summary:

    Diagnosis: Difficulty breathing and cough Treatment: Inpatient hospital admission The inpatient hospital admission was not medically necessary. This baby girl was referred to the ED by the pediatrician because of hypoxia with respiratory distress in the office. She was admitted because while in the ED she had episodes of desaturation to 88-92% in room air. While it was appropriate to continue monitoring this young infant for resolution of dehydration and need to apply supplemental oxygen, she was overall hemodynamically stable. She did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.

  • Reference:

    1) C Ravaglia, V Poletti. Recent advances in the management of acute bronchiolitis. F1000 Prime Reports 2014; 6:103ff. 2) Clinical practice guideline: The diagnosis, management, and prevention of bronchiolitis. Pediatr 2014; 134:e1474-e1502. 3) AR Schroeder, JM Mansbach, et al. Apnea in children hospitalized with bronchiolitis. Pediatr 2013; 132(5):1-8. 4) G Piedimonte. RSV infections: State of the art. Cleve Clin J Med 2015; 82(11 Suppl 1):S13- S18. 5) C Griffiths, SJ Drews, DJ Marchant. Respiratory syncytial virus: Infection, detection, and new options for prevention and treatment. Clin Microbiol Rev 2017; 30(1):277-319.
Cardiac/ Circulatory Problems
Inpatient Hospital
Fidelis Care New York
Overturned
Medical necessity
Female
60-69
2019
MCMC, LLC
201904-115712
201904-115712

  • Summary:

    Diagnosis: Recurrent angina Issue under review: Inpatient admission Determination: The inpatient admission was medically necessary. The patient presented for management of recurrent angina, and was noted to have obstructive disease of the RCA on cardiac catheterization. A coronary intervention with stent placement was performed on a CTO (chronic total occlusion), with use of dual injection and rotational atherectomy, which is considered a complex PCI. In addition the patient's course was complicated by a post-procedure myocardial infarction. Patients such as this one were excluded from the studies of outpatient PCI. It would be consistent with the current standard of care that this patient, after this complex PCI with the use of rotational atherectomy, be managed in an inpatient setting. Therefore, the requested inpatient admission was medically appropriate in this clinical setting.

  • Reference:

    1) Harrison's Principles of Internal Medicine, 17th Edition. Anthony S. Fauci , Eugene Braunwald , Dennis L. Kasper , Stephen L. Hauser , Dan L. Longo , J. Larry Jameson , Joseph Loscalzo 2) CURRENT Medical Diagnosis and Treatment 2010, Forty-Ninth 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)) - Hardcover (Oct. 16, 2007) by Peter Libby MD, Robert O. Bonow MD, Douglas L. Mann MD FACC, and Douglas P. Zipes MD 4) Outcomes of patients discharged the same day following percutaneous coronary intervention. Patel M, Kim M, Karajgikar R, Kodali V, Kaplish D, Lee P, Moreno P, Krishnan P, Sharma SK, Kini AS.JACC Cardiovasc Interv. 2010 Aug;3(8):851-8.
Genitourinary/ Kidney Disorder
Inpatient Hospital
Fidelis Care New York
Overturned
Medical necessity
Female
40-49
2019
MCMC, LLC
201904-115724
201904-115724

  • Summary:

    Diagnosis: SLE nephritis Treatment: Inpatient hospital admission The inpatient hospital admission was medically necessary. When there is evidence of bleeding post kidney biopsy, it is mandatory to admit the patient overnight or until no further bleeding. Patients can die from bleeding after a kidney biopsy. In addition, standard of care would warrant inpatient level of care over observation in this case since there was a life threatening bleed that requires greater than (>) 24 hours of monitoring.

  • Reference:

    1) The Native Kidney Biopsy: Update and Evidence for Best Practice Jonathan J. Hogan, Michaela Mocanu, and Jeffrey S. Berns Clinical journal of american soc of nephrology vol 17 2015. 2) Prasad N, Kumar S, Manjunath R, Bhadauria D, Kaul A, Sharma RK, Gupta A, Lal H, Jain M, grawal V: Real-time ultrasoundguided percutaneous renal biopsy with needle guide by nephrologists decreases post-biopsy complications. Clin Kidney J 8: 151-156, 2015.
Skin Disorders
Pharmacy/ Prescription Drugs
Fidelis Care New York
Upheld
Medical necessity
Female
10-19
2019
IMEDECS
201904-115738
201904-115738

  • Summary:

    This is a patient with severe atopic dermatitis, treated with multiple topicals including topical steroids, topical calcineurin inhibitors and Eucrisa. The provider is requesting Dupixent. The health plan's determination is upheld. The standard treatment options for patients with atopic dermatitis include a regimen of topical steroids as well as topical calcineurin inhibitors. After topical agents fail, standard practice is to pursue systemic therapy such as phototherapy.Since the documentation does not support that the patient has tried and failed phototherapy or a systemic immunosuppressant and does not have a contraindication to these, the requested Dupixent is not medically necessary..

  • Reference:

    1) Mennini M, Dahdah L, Fiocchi A. "Two Phase 3 Trials of Dupilumab versus Placebo in Atopic Dermatitis." N Engl J Med. 2017 Mar 16;376(11):1090. 2) Simpson EL et al. "Dupilumab therapy provides clinically meaningful improvement in patient-reported outcomes: A phase IIb randomized, placebo-controlled, clinical trial in adult patients with moderate to severe atopic dermatitis." J Am Acad Dermatol. 2016 Sep;75(3):506-515. 3) Han Y et al. "Efficacy and safety of dupilumab for the treatment of adult atopic dermatitis: A meta-analysis of randomized clinical trials." J Allergy Clin Immunol. 2017 May 4. 4) Blauvelt A et al. "Long-term management of moderate-to-severe atopic dermatitis with dupilumab and concomitant topical corticosteroids (LIBERTY AD CHRONOS): a 1-year, randomised, double-blinded, placebo-controlled, phase 3 trial." Lancet. 2017 May 4. pii: S0140-6736(17)31191-1. 5) Kraft M, Worm M. "Dupilumab in the treatment of moderate-to-severe atopic dermatitis." Expert Rev Clin Immunol. 2017 Apr;13(4):301-310. 6) Cork MJ et al. "Pharmacokinetics, safety, and efficacy of Dupilumab in a pediatric population with moderate-to-severe atopic dermatitis: results from an open-label phase 2a trial." Not yet published. 7) Sidbury R et al. "Guidelines of care for the management of atopic dermatitis. Section 4. Prevention of disease flares and use of adjunctive therapies and approaches." J Am Acad Dermatol 2014;71:1218-33. 8) Simpson EL et al. "When does atopic dermatitis warrant systemic therapy? Recommendations from an expert panel of the International Eczema Council." J Am Acad Dermatol. 2017 Oct;77(4):623-633. 9) Sidbury R et al. "Guidelines of care for the management of atopic dermatitis." J Am Acad Dermatol. 2018. 10) Wollenberg A et al. "Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part II." J Eur Acad Dermatol Venereol. 2018 Jun;32(6):850-878.4 Dec;71(6):1218-33.
Infectious Disease
Inpatient Hospital
CIGNA Healthcare of NY
Upheld
Medical necessity
Male
50-59
2019
IMEDECS
201904-115748
201904-115748

  • Summary:

    This patient has a history of multiple spinal surgeries with associated complications, including infections, hematomas and wound dehiscence. The patient had an initial instrumented lumbar fusion that became infected. The patient underwent further surgery for a spinal abscess with removal of the instrumentation. The patient was admitted to undergo a hematoma evacuation, wound debridement and closure of the wound. A rehabilitation stay was recommended. The health plan's determination of medical necessity is upheld. The infectious disease (ID) specialist noted that the patient was stable and recommended continuing the intravenous antibiotic Ceftriaxone for 6 more days to complete a 28-day regime, which could be accomplished at a lower level.

  • Reference:

    1) Chaichara K, Bydon M, Santiago-Dieppa D, et al. Risk of infection following posterior instrumented fusion for degenerative spine disease in 817 consecutive cases. J Neurosurg Spine. Jan 2014; 20(1): 45-52. 2) Piper K, Tomlinson S, Santagelo G, et al. Risk factors for wound complications following spine surgery. Surg Neurol Int. Nov 2017; 8: 269. 3) Wadhwa R, Ohya J, Vogel T, et al. Risk factors for 30-day reoperation and 3-month readmission: analysis from the Quality and Outcomes database lumbar spine registry. J Neurosurg Spine. Aug 2017; 27(2): 131-136.
Infectious Disease
Inpatient Hospital
Empire BlueCross BlueShield HealthPlus
Upheld
Medical necessity
Male
0-9
2019
IPRO
201904-115756
201904-115756

  • Summary:

    Diagnosis: Infectious Disease (Fever, Skin abscess) Treatment: Inpatient Hospital Summary: This patient presented to the Emergency Department (ED) for a chief complaint of an abscess of the left buttock. His parent reported there was fever the day prior to presentation. There was a family history of a sister with a recent skin abscess and a father with a past history of abscesses. On arrival, his temperature was 102.9°F, pulse was 140 and respirations were 26. Bloodwork revealed 21.3 white blood cells (WBCs) and 68.2% neutrophils. A bedside ultrasound showed a deep pocket abscess. Blood cultures were drawn, and intravenous (IV) Vancomycin was started. Pediatric surgery was consulted, and the patient was admitted with concern for signs of systemic infection, likely Methicillin-resistant Staphylococcus aureus (MRSA) given the recent family history. Antibiotics were continued and an incision and drainage was performed. Wound cultures grew moderate staphylococcus aureus and few Citrobacter freundii. The patient spiked a temperature of 101.2°F and was medicated with Ibuprofen. He was switched to oral antibiotics and discharged home in stable condition with outpatient follow-up planned. The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld. There was a family history of a sister with a recent skin abscess and a father with a past history of abscesses. These are described in the notes as being due to MRSA, but there is no evidence of that in the records. In fact, the subsequent culture report yielded methicillin-susceptible Staphylococcus aureus. The patient was fussy but consolable and well hydrated. A left medical gluteal abscess with a 2 cm induration was described. There was no mention of erythema of signs that would indicate extensive cellulitis. The ED physician's medical decision making note does not adequately justify the reasons for choosing IV antibiotics and a need for treatment as an inpatient. Although febrile, his vital signs were stable. There were no abnormal laboratory criteria other than leukocytosis (21,300/cu.mm), which reflects the bacterial soft tissue infection. The abscess was small and was incised and drained. IV Vancomycin was probably unnecessary, and antibiotics could have been continued orally following an initial IV dose. The medical necessity is not substantiated.

  • Reference:

    1) Kaplan S, et al. "Suspected Staphylococcus aureus and streptococcal skin and soft tissue infections in children >28 days: Evaluation and management." Uptodate.com 2) Lawrence HS, Nopper AJ. "Superficial Bacterial Skin Infections and Cellulitis." In: Long SS, Ed. Principles and Practice of Pediatric Infectious Diseases, 4th edition, 70, 427-435.e2. 2012, Elsevier Inc. Philadelphia, PA
Cardiac/ Circulatory Problems
Inpatient Hospital
Oscar Insurance Company
Upheld
Medical necessity
Male
30-39
2019
IMEDECS
201904-115767
201904-115767

  • Summary:

    The patient is a male with a family history of coronary artery disease (CAD) who awoke with a pleuritic, stabbing, non-radiating left sided chest heaviness, which improved with sitting up or lying on his right side and was aggravated by leaning forward and lying down. Other than mild shortness of breath (SOB) and shakiness, there were no additional associated symptoms. The health plan's determination is upheld. The patient presented with atypical chest pain, an EKG without clear cut evidence of acute myocardial infarction or ischemia and negative cardiac biomarkers. The inpatient stay was not medically necessary.

  • Reference:

    1) Braunwald's Heart Disease: A Textbook Of Cardiovascular Medicine. Author: Douglas Mann, MD, Douglas Zipes, MD, Peter Libby, MD, Robert Bonow, MD, MS. Affiliation: Publisher: Elsevier Health Sciences. Publication Date: 2015 2) Chapter 78 - Acute Coronary Syndrome | Section: Diagnostic Investigations. Rosen's Emergency Medicine, 8th; John Marx, MD, Elsevier Health Sciences, 2014 3) Chapter 50 - Approach to the Patient with Chest Pain | Section: Immediate Management. Braunwald's Heart Disease: A Textbook Of Cardiovascular Medicine, 2-Volume Set, 10th; Douglas Mann, MD, Douglas Zipes, MD, Peter Libby, MD, Robert Bonow, MD, MS, Elsevier Health Sciences, 2015 4) Chapter 195 - Observation Medicine And Clinical Decision Units | Section: Observational Approach. Rosen's Emergency Medicine, 8th; John Marx, MD, Elsevier Health Sciences, 2014 5) Hamm CW, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST- segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). European Heart Journal 2011;32(23):2999-3054. DOI: 10.1093/eurheartj/ehr236. (Reaffirmed 2014 Sep) 6) Evaluation of the adult with chest pain in the emergency department. Authors: Judd E Hollander, MD Maureen Chase, MD, MPH. Section Editor: Robert S Hockberger, MD, FACEP. Deputy Editor: Jonathan Grayzel, MD, FAAEM. UpToDate: Topic 288 Version 21.0
Cardiac/ Circulatory Problems
Inpatient Hospital
Empire Healthchoice Assurance Inc.
Upheld
Medical necessity
Male
40-49
2019
MCMC, LLC
201904-115782
201904-115782

  • Summary:

    Diagnosis: Atrial fibrillation Issue under review: Inpatient admission Determination: The inpatient admission was not medically necessary. This patient presented with syncope that occurred after standing up. The patient had multiple episodes of syncope in a short period of time and presented to the hospital for evaluation and treatment. Upon arrival, the patient was in atrial fibrillation with a rapid ventricular rate. Evaluation in the ED revealed no evidence of intracranial pathology on CT head. AF spontaneously reverted to normal sinus rhythm, and echocardiographic study revealed a structurally normal heart. Serum blood testing was significant only for marijuana use. The patient was discharged the following day. This patient presented with neural reflex syncope, a benign process. According to the European Society of Cardiology, this patient was a low risk patient for future morbidity and mortality (Reference 1). In a study of individuals presenting to the emergency room, patients that were low risk or intermediate risk for cardiac events had an excellent prognosis and did not require admission to the hospital for further testing (Reference 2). In this case, the patient falls into a low risk category, and he could have been managed a lower level of care. It would have been appropriate to manage the patient at a lower level of care.

  • Reference:

    1) Moya A, Sutton R, Ammirati F, et al. Guidelines for the diagnosis and management of syncope (version 2009): the Task Force for the Diagnosis and Man- agement of Syncope of the European Society of Car- diology (ESC). Eur Heart J 2009;30:2631-71. 2) Numeroso F. et al. Short-term Prognosis and Current Management of Syncopal Patients at Intermediate Risk: Results from the IRiS (Intermediate-Risk Syncope) Study. Academic Emergency Medicine 2016;23:941-948
Trauma/ Injuries
Inpatient Hospital
Empire BlueCross BlueShield HealthPlus
Overturned
Medical necessity
Male
0-9
2019
IPRO
201904-115826
201904-115826

  • Summary:

    Diagnosis: Non-accidental trauma Treatment: Inpatient admission, diagnostic testing, monitoring The insurer denied the inpatient admission. The denial was reversed. This child was brought by Emergency Medical Services (EMS) to the ER for evaluation. This child was reportedly punched on the left side of the face by an adult male. There was no loss of consciousness; the child cried immediately; no bleeding after being struck in the left parieto-temporal region. About two hours after the incident the patient had a small amount of non-bilious vomiting. The patient's vital signs and exam were all normal in the ED. No hematomas or active bleeding, except for a small scratch to left side of scalp. The case was reported to ACS (Child Protective Services). The patient was admitted for further work-up for Non-Accidental-Trauma (NAT) per the recommendation of the Pediatric Child Abuse Team: it was the recommendation by the Child abuse team to admit for skeletal survey, dilated eye exam and brain MRI. MRI of the brain, skeletal survey and ophthalmology work-up were within normal limits. The patient was discharged home with ACS follow-up. The MCG clearly states that inpatient admission is warranted for suspected abuse or neglect without other community options for management. Based on the MCG Health criteria for Pediatric admission and the mitigating circumstances in the encounter, the in-patient admission was medically necessary. The insurer's denial is reversed.

  • Reference:

    1) MCG Health: Pediatrics GRG, GRG PG-PED (ISCGRG). MCG Health General Recovery Care 2) Care Planning: Inpatient Admission and Alternative's, Pediatrics GRG-GRG