Persius/imr-appeals huggingface dataset:
Diagnosis: Obstruction of vision
Treatment: Blepharoplasty
The insurer denied the Blepharoplasty. 
The denial is overturned. 

The patient is a female for whom coverage of blepharoplasty (15823) is requested. Coverage was previously denied for lack of photos to support policy criteria. 

According to the provider, the patient had been complaining of obstruction of her vision for some time and had noticed that when physically holding up her forehead, she could see better, experiencing less fatigue and improved field of vision.  Marginal reflex distances were reported as 0.5 millimeters (mm) both eyes (OU).  Visual fields also reportedly improve by more than 30% with taping of the eyelids. An exam documents vision corrected to 20/25 OU. Dermatochalasis was characterized as three-plus (3+) OU with 3+ tenting temporally. One-plus (1+) cortical and nuclear sclerotic cataracts were noted OU.  

Yes, the blepharoplasty performed 06/10/2019 was medically necessary.

No, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  However, it should be noted that the health plan reportedly did not have the external photos that were provided for this current review.

According to general standards of practice supported in the peer reviewed literature, blepharoplasty procedures and repair of blepharoptosis are considered medically necessary when performed as functional/reconstructive surgery to correct impairment of near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis and/or symptomatic redundant skin weighing down on upper lashes. Typically, patient complaints which justify functional surgery include interference with vision or visual field, difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin. Photos should correlate with visual field testing.

A task force from the American Academy of Ophthalmology reviewed the functional indications and outcomes for blepharoplasty and blepharoptosis repair by assessing functional preoperative impairment and surgical results.  Ptosis and upper eyelid blepharoplasty surgery were found to be functionally beneficial for each of these quantitative findings:

1) Marginal reflex distance one (MRD1) of two mm measured in primary gaze (MET)
2) Superior visual field loss of 12 degrees or 24% (MET)
3) Down-gaze ptosis impairing reading documented by MRD1 of two mm measured in down gaze.

In this case, visual field testing performed within 30 degrees found superior visual fields restricted to near zero degrees OU, increasing to at least 30 degrees OU with taping of the eyelids. Black and white copies of external photos confirmed dermatochalasis with excess upper eyelid skin resting on the base of the lashes temporally and weighing down eyelids.  Marginal reflex distances are estimated as one mm OU. Photos correlate with the required superior visual field loss.  Therefore, medical necessity of bilateral upper eyelid blepharoplasty is established per standard of care.
Diagnosis: Cardiac / Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient stay. 
The denial was overturned in whole. 

The patient is a male with a history of significant multivessel coronary artery disease, coronary stents to the right coronary artery (RCA), left anterior descending (LAD), and first obtuse marginal (OM1), hypertension, type 2 diabetes mellitus, hyperlipidemia who presented to the emergency room (ER) with progressive exertional chest pain consistent with unstable angina. The patient underwent urgent coronary angiography demonstrating severe stenosis of the right patent ductus arteriosus (PDA) requiring drug-eluting stent (DES) placement. The patient was discharged the following day in stable condition.

The health plan's determination is overturned in whole. 

An inpatient stay was medically necessary for this patient.
This patient with known significant multivessel coronary disease requiring stents in the past and multiple risk factors for CAD presented with unstable angina in the setting of severe hypertension requiring urgent coronary angiography under the inpatient level of care. Urgent coronary angiography was medically appropriate with the goal of treating ischemic symptoms and reducing the risk of myocardial infarction. The patient presented with an elevated thrombolysis in myocardial infarction (TIMI) risk score (4) with an approximate 20% risk of future adverse cardiac events (all-cause mortality, new or recurrent myocardial infarction [MI], or recurrent ischemia requiring urgent revascularization) favoring benefit with urgent coronary angiography (1). Furthermore, according to the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) guideline for the management of patients with non-ST-elevation acute coronary syndromes, the standard of care for patients with unstable angina, as in this case, is admission for inpatient management to reduce ischemic symptoms and prevent myocardial infarction and death (2). For these reasons, inpatient level of care was medically appropriate and necessary in the best interest of this patient's safety.
Diagnosis: Autism spectrum disorder
Treatment: 97153 - ABA therapy, five hours/week 
The proposed treatment, ABA therapy, is not medically necessary.

This is an adult male diagnosed with autism spectrum disorder (ASD) at age three years; the source of that diagnosis is not documented. 

Despite the lack of evidence from randomized controlled trials, there is growing evidence from observational studies and systematic reviews and a consensus in the professional community that children with autism spectrum disorder (ASD) should participate in therapeutic programs as early as possible.  Almost all evidence concerning efficacy of psychosocial interventions in ASD is based on studies of children 18 months to seven years of age.  A systematic review concluded there was insufficient evidence (ie, not studied, poor-quality studies) to support the use of ABA therapy in the treatment of adolescents (such as this patient) or adults with ASD.  A systematic review of the effectiveness of behavioral, educational, life skills, or vocational interventions in people with ASD found variable effects on activities of daily living (ADLs), and have indicated that generalizability of positive findings in this area is limited due to insufficient evidence (ie, lack of study of some domains, poor quality studies).  Thus, the use of ABA for children age 12 years and older (such as this patient) must focus on the core features of ASD rather than on ADLs (which is not the case for this patient) [Smith 2015, Murza 2016, Reichow 2018, Volkmar 2018].
...
DURATION OF THERAPY.
The patient should receive ABA therapy for a minimum of 12 months, until:
1) Treatment goals are reached
2) Patient plateaus and fails to progress (i.e., maintenance therapy)
3) Four years of therapy

The diagnosis of ASD is not substantiated for this patient because clinical records fail to document a diagnostic evaluation for ASD by a qualified diagnostician (e.g., clinical child psychologist, board-certified child psychiatrist, board-certified child neurologist, board-certified developmental-behavioral pediatrician, board-certified neurodevelopmental pediatrician) administering an appropriate module of the ADOS-2 accompanied by review of the DSM-5tm diagnostic criteria along with standardized testing of intelligence and language.  Even if the diagnosis of ASD were substantiated, continued ABA therapy for more than four years is not medically necessary, appropriate, or standard of care.  Finally, the patient has shown poor RTI despite many years of ABA therapy, further supporting that the requested services are not medically necessary.
Cardiac/Circulatory Problems
Inpatient hospital

This is a case of a man with a history of hypertension diabetes and hyperlipidemia, presenting to the emergency room with complaints of left shoulder and arm pain, with radiation into the left hand. Symptoms have been present for at least a week, with associated intermittent headaches and blurred vision. The patient denied chest pain or shortness of breath. There was no associated nausea or vomiting. Vital signs on arrival included a temperature of 97.9 Fahrenheit, respirations of 26, and blood pressure of 204/127. The heart rate at this time is documented at 84 beats per minute (bpm). On exam, the patient is described as well-appearing well-nourished awake, and alert. The cardiac exam showed a regular rate and rhythm with normal heart sounds and no murmurs. The pulmonary exam was fairly unremarkable, and so was the rest of the exam. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. This presentation of hypertensive urgency can be managed under at a lower level of care. The presentation does not satisfy clinical indications for admission to inpatient care. The patient has a diagnosis of hypertensive urgency or emergency, without evidence of target organ damage. There is no evidence of hypertensive encephalopathy or cerebral infarction. There is no evidence that the patient suffered from myocardial ischemia or infarct. There is no evidence of heart failure or aortic dissection. There is no evidence of seizure activity associated with hypertensive urgency. Within 24 hours, the addition of antihypertensive medications produced adequate control of blood pressures. This type of presentation is typically managed at a lower level of care for chest pain rule out protocol.
Diagnosis: Rectal bleeding 
Issue Under Review: Inpatient admission 

Determination: The inpatient admission was not medically necessary. 

The patient is a male. He was admitted via the emergency department to the hospital.  The patient noted rectal bleeding and generalized weakness the morning of presentation. The impression was hemorrhoidal bleeding as the most likely cause. The patient evidenced anemia. 

On presentation, the patient had a hemoglobin of 6. He received two units of blood and evidenced no bleeding during the hospitalization. The patient was discharged with a plan for close follow-up. 

The patient presented with anemia and received two units of blood. The patient evidenced only generalized weakness from the anemia. There was no reported hypoxia, active bleeding, coagulopathy, or planned surgery. The care as rendered could have been delivered at a lower level of care in its entirety.
Diagnosis: Fecal Impaction

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with a medical history of hemorrhoidectomy and an abdominoplasty. The patient presented to the Emergency Department (ED) with complaints that she had not had a bowel movement since the hemorrhoidectomy. The patient had been diligently taking her opioids and eating regularly.  The patient denied abdominal pain, but did complain of nausea. She reported that sometimes she passed gas but had not passed gas on the date of presentation. Her presenting vital signs were: blood pressure 106/71 and temperature 36.7 C.  A physical examination was performed that revealed her abdomen was soft and non-tender. An abdominal x-ray was done that revealed no evidence of free air or obstruction. The patient's surgeon recommended she come to the ED for an enema under sedation. The patient underwent an examination under anesthesia, minimal fecal disimpaction, and irrigation of the rectum with saline and Betadine. The patient was discharged in stable condition.

Based on the review of the medical record and literature, the inpatient admission was not medically necessary. The patient had post-operative constipation compounded by opiate use. The patient was hemodynamically stable and her labs were unremarkable. The patient's abdominal imaging did not reveal ileus or obstruction. While fecal disimpaction was appropriate, inpatient admission was not medically necessary. The patient could have received her care in the Emergency Room (ER) or at Observation level of care. 

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial should be upheld.
Diagnosis: Autoimmune encephalitis with refractory seizures 
 Treatment: Octagam 

The insurer denied coverage for Octagam. The denial is reversed. 

This patient is a male who has been previously diagnosed with Crohn's disease.  A letter of medical necessity indicates the patient was also being seen by Neurology for a complex neurological condition.  The patient was noted to have autoimmune encephalitis with secondary intractable epilepsy.  The patient had an explosive onset 6 months prior with multiple and refractory focal seizures with secondary generalization captured during a prolonged hospital stay.  The patient has undergone extensive evaluation to include CSF examination which returned a positive result for high levels of myelin basic protein.  The patient did respond well to an initial course of Solu-Medrol and an attempt to taper then led to worsening seizure frequency.  The patient was utilizing 2 AEDs at very high doses in combination with oral prednisone.  The patient was recommended to continue chronic immunosuppression.  

Additional submitted documentation does include a chart note when the patient was seen for a follow-up.  The documentation did detail the patient was recently admitted for an episode worsening seizures.  The patient responded well to Solu-Medrol in addition to valproic acid (VPA).  The patient did attempt to taper off steroids as noted above however this worsened the seizures.  The documentation detailed the patient was feeling okay since the hospital visit.  The physician indicated the patient presented with a new onset seizure-like event following a fall.  By description and video review, events are atypical for seizures; however recent evaluation confirmed the epileptic nature.  The documentation indicated the recent emergent admission in response to Solu-Medrol, as well as worsening seizures with steroid discontinuation, supports the autoimmune etiology of epilepsy.  It was recommended the patient continue multiple medications and begin IVIG.  

IVIG is commonly used for cases of autoimmune encephalitis with refractory seizures and is in the standard of care. A variety of clinical studies, some randomized, blinded studies have shown efficacy with IVIG.  Therefore, the use of Octagam is medically necessary in this case for this patient with treatment failure with steroids and multiple anticonvulsant medications.  The decision is overturned and Octagam should be approved in this case.  

The health plan did not act reasonably and with sound medical judgment in the best interest of the patient.  

Based on the above, the medical necessity for Octagam is substantiated.  The insurer's denial is reversed.
Diagnosis: Malocclusion

Treatment: Braces and monthly visits

The insurer is denied coverage for the braces (D8080) and monthly visits (D8670). 

The denial is upheld. 

The patient was a male child. Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care.  The orthodontist identified several clinical findings including anterior crowding, overjet and overbite and has recommended orthodontics. The orthodontist has completed the HLD index attaining 11 total points to support orthodontic care.  

It is evident that the patient exhibited a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labio-Lingual Deviation Index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating Orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 11 points to justify for this patient's orthodontic care.  This reviewer concurs with the index completed by this patient's orthodontist attaining a total of 11 points on the HLD index (1 points overjet, 1 points overbite, 5 points anterior crowding, 4 points labiolingual spread) which is below the threshold of 26 points to support orthodontic care.  Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Since this patient's HLD index total score was 11, which was below the threshold of 26 points to justify for orthodontic care, the braces and the monthly visits associated with braces are not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the braces (D8080) and monthly visits (D8670) should be upheld.  The medical necessity is not substantiated.
Diagnosis:  Endocrine/Metabolic - Diabetes. 
Treatment:  Pharmacy Prescription drugs.  
The insurer denied medication Afrezza.  The denial is overturned.


The patient who has been diagnosed with type 1 diabetes since the age of 10 years.  The patient has been treated with multiple daily insulin injections.

The requested health service treatment of Afrezza is medically necessary for this patient.  Glycemic control is fundamental to the management of diabetes.  The Diabetes Control & Complications Trial (DCCT) study showed definitively that improved glycemic control is associated with significantly decreased rates of microvascular (retinopathy and nephropathy) and neuropathic complications.  As intensive diabetes management is associated with significantly decreased rates of microvascular and neuropathic complications, target HbA1C should be < 7% and achievement of HbA1C < 6.5%, if achieved safely without significant hypoglycemia, may be acceptable.

This patient has been diagnosed with type 1 diabetes, and control has been excellent; however, she has developed lipoatrophy associated with multiple daily insulin injections, so the patient is on inhaled insulin to minimize the number of injections that are medically necessary and reasonable, as the patient had developed lipohypertrophy from insulin injections, which ultimately led to lipoatrophy.
Diagnosis: Alcohol withdrawal; history of polysubstance abuse
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with a history of polysubstance abuse. She was admitted to the medical floor from detox for alcohol withdrawal after wanting to sign out AMA (against medical advice).  

The patient's VS (vital signs) were as follows: 97.9, 77, 18, 148/92, 96%. Her exam was unremarkable. She exhibited no signs of DTs (delirium tremens). She had no neurologic deficit. CBC (complete blood count) and BMP (basic metabolic panel) was unremarkable. EKG (electrocardiogram) revealed NSR (normal sinus rhythm). Head CT showed NAD (no active disease). The plan was for management with Librium tapering dose. The patient had no capacity per Psych evaluation. The patient was placed on one-to-one for elopement risk per psych. The plan was for consult psych for reevaluation. The patient's alcohol withdrawal resolved. She was cleared for discharge. 

This patient was admitted for management of alcohol withdrawal and discharged. The patient was hemodynamically stable and afebrile. She did not have tachycardia. She did not have persistent vomiting. She did not have gross tremor. Labs were unremarkable. The plan was for management with Librium taper. The patient was clinically stable and did not have findings of alcohol withdrawal. She did not have symptoms that required an acute inpatient level of care. The requested inpatient admission was not medically necessary.
Diagnosis: Dental issue

Treatment: Dental core buildup on tooth #30

The insurer denied coverage for D2950, (core buildup, including pins) on tooth #30

The denial is overturned.

This is a female patient who was seen for evaluation of dental issues.  The treating dentist is requesting authorization for D2950 (core build up, including pins) for tooth #30.  

Upon review of the submitted documentation, the patient exhibited endodontic therapy on #30 completed in Russia.  Based on these clinical findings, the dentist recommended core buildup on this tooth, presumably prior to crown placement. The insurer has denied this service stating that the quality of the endodontic therapy, i.e. poor quality obturation and fill, does not support these treatments.  The treating dentist states that the "cement" used as a filling material does not negatively affect long term tooth retention/health.

The existing restoration placed on this endodontically treated tooth appears to be failing. Given this clinical circumstance, core buildup and placement of full coverage crown is indicated and is a conservative restorative option which would represent a standard of care for this clinical circumstance in general dental practice. As such the service noted above, which is a covered service for this individual, is deemed medically necessary.

The health care plan did not act reasonably and with sound medical judgement and in the best interest of the patient. 

The carrier's denial of coverage for D2950 (build-up) on tooth #30 is overturned.  The medical necessity is substantiated.
Diagnosis: Cellulitis, Abscess
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial was overturned.

This is female patient with immunocompromised status and a past medical history significant for substance abuse and depression. The patient presented to the Emergency Department (ED) with complaints of right ankle swelling and erythema.  The patient's vital signs on presentation were: temperature 98.2 F, blood pressure 147/76, pulse 86, respiratory rate 20, and oxygen (O2) sat-99% on room air. The patient's laboratory results included the following: white blood cell (WBC)-11.4, hemoglobin-11.6, hematocrit-36.3, creatinine-0.91, glucose-167, ESR-69, CRP-1.1, and urine toxicology positive for cocaine and opiates. The patient was admitted to the hospital for cellulitis/abscess of the right ankle; she received intravenous (IV) antibiotics. Surgery was consulted and an incision and drainage (I&D) was performed. The patient's wound culture grew methicillin-resistant staphylococcus aureus (MRSA). The patient refused magnetic resonance imaging (MRI). The patient received wound care. The patient had an episode of hypotension prior to signing out against medical advice (AMA).  

According to medical record, the patient presented with a right ankle abscess. The patient's laboratory results showed elevated white blood cell (WBC) count, anemia, and increased ESR. The patient's urine toxicology was positive for substance abuse. Based on these clinical findings in a high-risk patient with immunocompromised status, inpatient admission was medically necessary for administration of intravenous antibiotics and surgical intervention.    

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient admission is substantiated.  The insurer's denial is overturned.