Persius/imr-appeals huggingface dataset:
This is a patient with a past medical history significant for uterine fibroids, goiter, and hemorrhoids who was referred to the emergency department by her primary care physician because of anemia. At the time of the initial evaluation, the patient denied any injury, overt bleeding, or blood in the stool or urine. She denied any excessive bleeding or bleeding between the menstrual cycles. The review of systems was positive for generalized weakness, otherwise negative.
At the time of the initial evaluation patient's temperature was 99.1 degrees Fahrenheit (F), pulse rate 105, respiratory rate 19, blood pressure 125/56, and oxygen saturation was 100% on room air. The rest of the physical exam was unremarkable. An EKG demonstrated normal sinus rhythm, no evidence of ischemia.
The health plan's determination is upheld. The inpatient admission was not medically necessary. A fecal occult blood test was negative. Anemia workup was initiated. The patient was ordered infusion of two units of packed red blood cells. During the hospital stay, the patient remained afebrile and hemodynamically stable. It was noted in the discharge summary that the patient's anemia was most likely due to iron deficiency. It was also noted that the etiology was still unknown at the time of discharge. The patient had no active massive hemorrhage, active hemolysis or rapidly progressive anemia, hemodynamic instability, cardiovascular symptoms such as dyspnea, chest pain. There was no evidence of heart failure, neurologic symptoms, cardiac arrhythmias of immediate concern, acute peripheral ischemia, high-risk low platelet count, or any other conditions necessitating admission at the inpatient level of care. There was no need for any procedures or diagnostic tests necessitating inpatient level of care.
The patient has a past medical history significant for recurrent diabetic foot ulcers with right toe amputation due to osteomyelitis, neuropathies, obesity, cerebrovascular accident (CVA) with left sided hemiparesis and non-ST elevation myocardial infarction (NSTEMI). Request is for a power wheelchair.  Power Wheelchair is not medically necessary for this patient. Provider notes that the patient is able to use a walker in the home. The use of an electric scooter/wheelchair outside of the home is not appropriate. If the patient is able to use a walker in the home patient should be capable of using a manual wheelchair outside of the home. Therefore, a customized manual wheelchair is more appropriate and within the generally accepted standards of medical care. The HP determination is upheld.
Diagnosis: Back and neck pain
Issue under review: Increase in consumer directed personal care assistance services

Determination:
The Increase in consumer directed personal care assistance services is medically necessary.

The patient has a history of chronic low back and neck pain. Due to these conditions, she has difficulty ambulating with associated gait ataxia, frequent falls and difficulty completing her activities of daily living (ADLs). Furthermore, her chronic musculoskeletal pain and decreased range of motion have rendered her chronically homebound, as she is unable to sit/stand/walk for prolonged periods of time longer than 20 to 30 minutes. In addition, she is restricted from bending/pushing/crouching/squatting/stooping and lifting/carrying greater than 10 lbs, per functional assessment statement. For these reasons, the proposed treatment of an increase in consumer directed personal care assistance services from 30 to 40 hours per week is deemed medically necessary.
Diagnosis: Liver Disease/Fatty Liver
Treatment: Magnetic Resonance Imaging, Abdomen

Summary:
No, the proposed MRI abdomen/MRCP is not appropriate and medically necessary for the evaluation and management of fatty liver and simple liver cyst. The patient has mild elevation of ALT due to underlying fatty liver disease. She had an MRI of the abdomen in December 2016, which revealed fatty liver disease and a small 3mm cyst in the right lobe of the liver. There was no evidence of biliary disease/obstruction/ or primary sclerosing cholangitis (PSC). Since there is no evidence of biliary obstruction or biochemical evidence of cholestasis (intra- or extra-hepatic cholestasis) based upon the liver function tests, no further evaluation is required.
Diagnosis: Melanoma
 
Treatment: The DecisionDX-Melanoma Assay test

The insurer denied the  DecisionDX-Melanoma Assay test. The denial was upheld.

This is a male patient with a history of Melanoma. According to his surgical pathology report, he had a melanoma 2.3 millimeter thickness and a basal cell carcinoma on the left side of his forehead. As recommended, the patient underwent further testing for his diagnosis. The test revealed that the patient was a low risk for a reoccurrence.
 
The DecisionDx-Melanoma, a 31-gene panel assay, is stated to determine the risk of recurrence and metastases of the melanoma. However, the test is still investigational and is not the standard of care. According to the National Comprehensive Cancer Network (NCCN), routine genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study.  Given that the current recommendations at this time do not include the use of DecisionDX gene expression testing and the current peer-reviewed literature shows studies are needed to identify the clinical utility of such testing, the DecisionDX UM testing is not medically necessary.

Based on the above, the medical necessity for the Decision DX-Melanoma Assay test is not substantiated.  The insurer's denial is upheld.
Diagnosis: Syncope versus seizure
 
Treatment: Brain magnetic resonance angiography

The insurer denied the brain magnetic resonance angiography. The denial was upheld.

This is a female with a past medical history of cervical pain, migraines, fibromyalgia, syncope and anxiety.  She had mild migraines until several years ago; not recently an issue.  The patient had previous fainting spells which she felt were due to dehydration. She reported 3 episodes of feeling like she was going to pass out, followed by headache, right-sided numbness/paresthesia, and loss of consciousness.  There was no seizure activity, urinary incontinence or tongue biting.  A magnetic resonance imaging (MRI) of the brain was normal. Given the patient's clinical history and MRI of the brain, further imaging including a MR angiography (MRA) of the head and neck was felt to be medically necessary.

Medical literature indicates head MRA may be indicated if aneurysm or arteriovenous malformation is known or suspected, as indicated by follow-up monitoring for a patient with a history of subarachnoid hemorrhage, aneurysm or arteriovenous malformation, initial evaluation of suspected aneurysm or arteriovenous malformation, or re-evaluation after surgical or endovascular therapy for cerebral artery aneurysm or arteriovenous malformation.  The physician had concern for syncope versus seizure.  An electroencephalogram (EEG) was ordered.  MRI of the brain did not reveal evidence of infarct, mass lesion or hydrocephalus. The patient was to undergo an MRA of the head/neck to exclude the presence of an underlying vascular lesion or dissection.  The patient did not require follow-up monitoring for a history of subarachnoid hemorrhage, a known aneurysm or arteriovenous malformation, and did not require a head MR angiography for initial evaluation of a suspected aneurysm or arteriovenous malformation, such as an acute severe headache.  There was no other indication as to why an MRA of the brain would be appropriate.  

The carrier's denial of coverage for the brain magnetic resonance angiography (MRA) is upheld.  The medical necessity is not substantiated.
The patient has cocaine, alcohol, opiate and cannabis dependence and was admitted to an inpatient detox service. Patient endorsed typically using alcohol, heroin and cocaine daily. The reported  last use of cocaine and heroin was the day prior, but had drunk two 24 ounce beers earlier that day. Blood alcohol level was zero and urine was positive for cocaine, opiates and tetrahydrocannabinol (THC). Complained to nursing of hot/cold sweats, tremors, diarrhea, headache, abdominal pain, and joint pain. Initial vital signs included a mildly tachycardic pulse of 105 and a normal blood pressure of 128/72. To the nurse practitioner patient complained of the same symptoms; in addition,  nausea, anxiety, irritability, diarrhea, and teary eyes. The physical exam did document tremors and a flushed appearance. The initial Clinical Institute Withdrawal Assessment (CIWA) score was 16 and Clinical Opiate Withdrawal Scale (COWS) was 15.
The patient reported a psychiatric history of anxiety, depression, and post-traumatic stress disorder (PTSD). Denied current suicidal thoughts and denied current outpatient treatment. Has a history of suicide attempt while intoxicated on alcohol. Patient reported over 100 past treatment episodes and has serious legal and personal consequences from use. Patient was admitted to the detox unit and placed on methadone and Ativan withdrawal protocols. The service of inpatient detoxification treatment was medically necessary The patient has a documented history of chemical dependence on multiple substances (opiates, alcohol, cocaine, and cannabis). Patient has a shelter bed but does not have a sober support network. The CIWA, COWS and physical exam on admission all are consistent with clinically significant withdrawal. Of the substances used, the potential for alcohol withdrawal is the most clinically serious given that alcohol withdrawal can be fatal. Patient does not have a known history of serious withdrawal, but serious withdrawal can manifest at any time in the illness course. The chronicity and amount of  use also places patient at increased risk for withdrawal. The combination of alcohol withdrawal with opiate withdrawal does increase risk of medical complication. An admission LOCADTR  resulted in a recommendation for inpatient services. The HP determination is overturned in whole.
This is a patient a past medical history significant for hypertension and gastroesophageal reflux disease (GERD) who presented to the emergency department (ED) with complaints of high blood pressure. Apparently, the patient did not take her blood pressure medications on the day of the presentation to the ED. While in the emergency department, the patient started to have left-sided chest pain that radiated to the left arm. She described the pain as throbbing, non-exertional. The patient also complained of epigastric abdominal pain and nausea. It was associated with sweating and palpitations.
During the hospital stay, the patient was ruled out for acute coronary The health plan's determination of medical necessity is upheld. The patient presented with atypical chest pain. Considering her risk factors, which included hypertension and hyperlipidemia, it was appropriate to rule out acute coronary syndrome and this was ruled out. The patient was seen by the cardiology service and was found to have atypical chest pain. No intervention was needed.
Even though the patient came to the hospital with elevated blood pressure, there was no evidence that she had a hypertensive emergency or any other complications that would require management of the blood pressure in inpatient settings.
The patient presented to the hospital in early 2019. The patient had a history of chronic lymphedema, recurrent lower extremity cellulitis, and scrotal cellulitis. The patient presented complaining of lower extremity edema, warmth, and scrotal pain. The patient's symptoms were worse on the left side. He also reported fever, sore throat, and nausea. The patient denied chest pain, shortness of breath and diarrhea. The plan of care included intravenous (IV) antibiotics, IV fluids, blood cultures, lower extremity ultrasound, ultrasound of the scrotum, and consider iron supplementation. 

The health plan's determination is overturned. The inpatient stay is medically necessary. The patient presented with sepsis and cellulitis and had some evidence of hemodynamic instability with tachycardia. He required IV antibiotics and there was concern for toxic shock initially as a possible complication of the patient's presentation. In addition, the white blood cell count was markedly elevated and he had a relatively high fever. The patient was it increased risk of having an adverse outcome because of these factors and it would not have been appropriate to manage at a lower level of care.
The patient was referred from the High Risk OB clinic for admission for glycemic control. The obstetrical history was significant for 1 cesarean section. The patient had history of 2 prior admissions for glycemic control. On presentation, the patient's blood glucose was 61. There were no obstetrical complaints. Fetal heart rate tracing was reassuring. The inpatient admission is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. Based on provided clinical information, the records did not indicate any evidence of hyper/hypoglycemia; fetal heart rate tracing and ultrasound examination were normal; the patient was hemodynamically stable. there was no evidence of ketoacidosis; there was no abnormal bleeding, PPROM (Preterm premature rupture of the membranes) or preterm labor. Insulin regimen (each dose) was increased only by 2 units; the initial and subsequent FS assessments were all normal.
The patient is a previously healthy female, whose family has limited English proficiency, who presented to the emergency department (ED) with fevers, vomiting and diarrhea. Symptoms began approximately 1 month prior with waxing and waning course. There were no associated respiratory symptoms or recent travel. Of note, ED records indicate that this child was still nearly exclusively breast fed.

Labs showed white blood cell (WBC) count of 12 with 44 segs and 43 lymphs, hematocrit (Hct) 32, and platelets (Plt) 562. Sodium (Na) 136, potassium (K) 4.0, chloride (Cl) 105, carbon dioxide (CO2) 15, blood urea nitrogen (BUN) 10, creatinine (Cr) 0.45, and glucose (66). Liver function tests (LFTs) and bilirubin were normal. Initial urinalysis (UA) showed specific gravity (SG) 1.020 and small ketones. The patient received intravenous fluids (IVF) bolus x 2 and intravenous (IV) Zofran. She was admitted to the pediatric ward where she continued to receive IVF and advance diet as tolerated. Her diarrhea and other symptoms improved, and she was able to be discharged home two days later.

The health plan's determination is upheld.

The requested inpatient stay was not medically necessary for this patient.
This patient was hemodynamically stable with mild dehydration secondary to acute gastroenteritis. She received 2 IVF boluses in the ED, but reportedly failed an oral challenge so was admitted to the hospital. Hospital notes indicate continued diarrhea, but do not indicate continued vomiting or other complications. Therefore, based on patient condition her care could have been managed at a lower level of care status.
Diagnosis: Substance Abuse

Treatment: Inpatient Substance Detoxification 

The insurer denied the Inpatient Substance Detoxification. The denial was reversed. 

This is a middle aged male who was admitted for inpatient substance detoxification treatment in late 2018 for heroin and crack/cocaine detoxification. He reportedly was using IV heroin and crack/cocaine use since a young age. He had withdrawal symptoms including nausea, sweats, yawning, tremors, anxiety, gooseflesh skin, and generalized body aches. He had a history of inpatient substance detoxification and rehabilitation treatments. During hospital admission he was placed on a Methadone taper and was then discharged home.

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

In this case this patient had been using large amounts daily of heroin and crack/cocaine. According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as he continued to use multiple serious substances of abuse daily with a long history despite reports that he had multiple past inpatient substance detoxification and rehabilitation treatments. The patient also required and needed detoxification medication to modify withdrawal and needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms including severe withdrawal and also was at high risk for overdose so he required this 24 hour inpatient detoxification setting then. Also, he likely would have relapsed again as evidenced by relapsing after past treatments so it was not likely that he could safely and effectively be treated for detoxification in an outpatient setting. It was unlikely that he would remain abstinent while having withdrawal symptoms which he reportedly had as he had reports of withdrawal symptoms including nausea, sweats, yawning, tremors, anxiety, gooseflesh skin, and generalized body aches.

Based on the above, the medical necessity for the inpatient hospital services at the inpatient detoxification level of care is substantiated. The insurer's denial is reversed.
Diagnosis: Dental Problems-edentulous spaces

Treatment: Dental implants placement

The insurer has denied coverage of dental implants placement. The denial was upheld.

This is a male patient who presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for edentulous spaces in the anterior maxilla incisor area with missing teeth #7 and #10.  It appears that the patient completed orthodontic therapy and was wearing a removable prosthesis to replace the missing teeth. The orthodontist discussed treatment plans, which included no additional treatment, fixed or bonded bridges or endosteal implants (with grafts) and implant retained crowns. The patient chose endosteal implants to be placed at the sites after discussion of treatment plans.  

The insurer has denied the aforementioned services, stating that in their estimation, endosteal implants are not the only procedure or appropriate treatment. They further state that these services are exclusions from the patients' medical plan coverage, and the insurer will only cover certain dental services under the medical coverage with very specific criteria to be met. Therefore, the endosteal implants are considered not medically necessary, considered elective and therefore no benefit is available.  The patient is appealing the decision.

Upon review of the objective documentation, which primarily consists of the panoramic radiograph, it is evident that the patient exhibits edentulous spaces in the areas of #7, 10. As regards to endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry includes a fixed bridge of some type. Further, a functional impairment is not documented objectively and none appears to be present; therefore, no actual treatment is required and an option is to do nothing.  

Uphold denial of coverage of dental implant placement (21248) and bone graft (21210) as not medically necessary since there is no functional deficit documented. The insurer acted reasonably, with sound medical judgement, and in the patient's best interest.

Based on the above, the medical necessity for Dental Implant Placement (21248) and Bone Graft (21210) is not substantiated. The insurer's denial is upheld.
Diagnosis:  Infectious colitis
Treatment:  Inpatient stay 
The acute inpatient admission was not medically necessary.

Summary:
The patient was a female, who presented via ambulance to the ED with the complaints of nausea, vomiting and abdominal pain.

The patient was admitted to start treatment for infectious colitis.  The patient was maintained NPO (nothing by mouth) on intravenous (IV) fluids, IV antibiotics, Zofran and a proton pump inhibitor for acute management of acute infectious colitis.  The patient's tachycardia resolved when her pain was controlled and after getting fluids.  The patient had a repeat set of labs, which showed resolution of the leukocytosis, which lowered the suspicion for a systemic infection cause in this patient.  The patient was taken off antibiotics, and her cultures later returned confirming no bacteremia.  She symptomatically improved, and her vomiting stopped.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care.  The patient had infectious colitis; yet, she did not evidence 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.  As such, the care could have been rendered at a lesser level.
This patient presented to the emergency department with complaints of three days of intermittent shortness of breath and chest pain. His blood pressure was 119/80 millimeters of mercury (mmHg) with a heart rate of 61 beats/minute. His room air oxygen saturation was 96%. His cardiovascular exam was unremarkable. His electrocardiogram was normal. His serum troponin level was normal. His hemoglobin level was increased at 19.9 grams per deciliter (g/dl). A chest x-ray showed no acute disease. He was treated with nitroglycerin and intravenous hydration and admitted to the hospital to rule out acute coronary syndrome. The health plan's determination is upheld.  Observation until acute coronary syndrome (ACS) could be ruled out was a reasonable approach. A myocardial perfusion study was performed and was normal. He was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. There is no indication in the records provided that other potentially life-threatening causes of his chest pain were thought to be likely. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with 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 patient underwent upper and lower jaw surgery and went home the next day. There were no complications noted. The inpatient admission is under review. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. Most patients with this surgery (orthognathic) are treated, observed and discharged the same day or the following day as long as discharge criteria is met. The surgery is accomplished in an operating room (OR) setting and the minimum required to accomplish the surgery. An inpatient setting would not be necessary unless discharge criteria is not met. In the United States, it has been reported that between 46% and 84% of patients go home the same day of surgery after an orthognathic procedure. It is rare for an orthognathic surgery patient stay to extend beyond the first postoperative day following a 3.5-hour bimaxillary surgery. A study of patients who underwent orthognathic surgery at Massachusetts General Hospital between January 1994 and July 2006 found that individual variables associated with duration of length of stay (LOS) are complexity of the orthognathic procedure and type of fixation used. In the multiple logistic regression model, LOS decreases significantly when rigid fixation, hypotensive anesthesia, and perioperative steroids are used in combination. In this patient's case, there were no postoperative complications, therefore the patient could have been cared for at a lower level of care.