Persius/imr-appeals huggingface dataset:
Diagnosis: Type 2 Diabetes Mellitus
Treatment: Mounjaro
The insurer denied Mounjaro.
The determination is upheld.

This is a female patient diagnosed with type 2 diabetes mellitus (T2DM). This request is for Mounjaro. She states that she started metformin and then tried Ozempic and with both, she suffered adverse side effects. She failed metformin due to stomach cramping and almost daily diarrhea. She paid a subscription for Weight Watchers. She is using Mounjaro and doing well; her glycated hemoglobin (A1C) was 4.7 percent (%). Her A1C was 7.9 %.  She has obesity, anxiety and depression. She has been on Ozempic and her sugars improved and her weight is down but she had terrible gastrointestinal (GI) side effects, nausea and an upset stomach. It was not reported in this visit note that she has T2DM. At issue is the medical necessity of Mounjaro.

The requested medication Mounjaro (Trizepatide) is Food and Drug Administration (FDA) approved for the treatment of adults with type 2 diabetes. It is a glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP) receptor agonist. It has been shown in clinical trials to lead to improvement in hemoglobin A1c as well as weight loss (1-3).
There are no studies demonstrating the superiority of the requested medication over the formulary alternatives. The most recent American Diabetes Association guidelines recommend using GLP-1 receptor agonists as a first line agent. There is no preference for the requested medication over GLP-1 receptor agonists(4). The patient failed Ozempic. The patient can try one more formulary alternative. The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary.
Diagnosis: Alcohol abuse. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The health plan's determination is upheld. 

The patient is a male who initially presented to the emergency department with request for alcohol detoxification. Pertinent history included diabetes mellitus, alcohol use, and smoking crack. No history of alcohol withdrawal seizure or delirium tremens are noted. Initial vital signs revealed a temperature of 97.5F (Fahrenheit), heart rate (HR) 81, blood pressure (BP) 112/71, respiratory rate (RR) 18, and oxygen saturation 100% on room air. Initial examination documented the patient as alert and oriented with evidence of acute intoxication. 

The inpatient hospital admission was not medically necessary. The patient had a history of alcohol use disorder without prior withdrawal seizures or delirium tremens who presented with acute alcohol intoxication requesting detoxification. Initial examination documented the patient as alert, oriented, and with stable hemodynamics. Initial evaluation was relatively unremarkable with the exception of hyponatremia. Treatment included intravenous fluids and CIWA (Clinical Institute Withdrawal Assessment) with benzodiazepines as needed. Following observation care, the CIWA was documented as 0 and no benzodiazepines had been indicated / administered for a 24 hour period. The patient was deemed medically stable for discharge with a similar serum sodium level as on arrival. No other issues or complications were documented. A lower level of care was appropriate.
Diagnosis: back surgery
Treatment: inpatient stay
The insurer denied an inpatient stay. The health plan's determination is overturned. 

The patient is a female with a history of low back pain and L (left) leg symptoms for 2 years. Prior treatments include physical therapy (PT) and other conservative treatments. The patient was taken to the operating room (OR) and underwent L (lumbar) 4-S (sacral) 1 laminectomy and fusion. Intraoperatively, one drain was placed. No complications were reported. Foley was discontinued on postoperative day (POD) 1. Lovenox and SCDs (sequential compression devices) were ordered for deep vein thrombosis (DVT) prophylaxis. Physical therapy (PT) and occupational therapy (OT) were ordered for post-operative rehabilitation. A PM&R (physical medicine and rehab) consult was placed for post-operative care. 

The inpatient hospital admission was medically necessary.
The patient underwent a L (lumbar) 4-S (sacral) 1 fusion. She experienced no complications post-operatively. She was able to be safely discharged home on postoperative day (POD) 4 after expected recovery as an inpatient in the hospital. Lumbar fusion benchmark length of stay is 1-3 days and standard of care is to perform this as an inpatient. Given the invasive nature of this major surgical procedure and the necessary post-operative care as per above, inpatient care was medically necessary post-operatively. The treatment received was within generally accepted standards of medical practice and would be clinically appropriate at the inpatient level of care. The patient does not meet a lower level of care due to the complexity of her procedure and necessary care as per above. Therefore, inpatient admission on the denied days was medically necessary.
Diagnosis: Viral pharyngitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with no past medical history (PMH) who was admitted with complaints of (c/o) a sore throat associated with a fever. Imaging studies included a chest x-ray (CXR) which showed possible right lower lobe (RLL) community acquired pneumonia (CAP), a computed tomography (CT) scan of the abdomen/pelvis (A/P) showed no acute pathology, a CT scan of the chest showed no pneumonia. The patient was diagnosed with CAP and treated with intravenous (IV) antibiotics and intravenous fluids (IVF), but was eventually diagnosed with viral pharyngitis and antibiotics were discontinued. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) a sore throat associated with fever. The patient was initially diagnosed with CAP and treated with antibiotics. The patient was hemodynamically stable, did not require intubation, non-invasive positive pressure intubation, did not have any severe respiratory distress, tachypnea, use of accessory muscles in neck, severe intercostal retractions, cyanosis, new altered mental status (AMS), hypoxia, and the CURB-65 [confusion, uremia, respiratory rate, blood pressure (BP), age greater than or equal to (>=) 65 years) score was 0, indicating a low-risk patient. The pneumonia severity index was risk class I, indicating that outpatient therapy was reasonable. The patient was ultimately diagnosed with viral pharyngitis and treated with IV fluids and antibiotics were discontinued, and overall care could have been safely provided at a lower level of care.
Diagnosis: Dental Disorder
Treatment: Braces and monthly visits
The insurer denied Braces and monthly visits.
The determination is overturned.

This is a female patient who presented with a skeletal Class III malocclusion with spacing in the maxilla and the mandible. She also has a 4 millimeter (mm) anterior open bite. She is treatment planned for 30-36 months of orthodontics to address the spacing, crossbite, and open bite. At issue is the medical necessity of braces and monthly visits.

Patients with an anterior open bite are among the most difficult patients to treat. (1) One side effect of an anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. (2)
Studies have shown that patients with severe malocclusions, including anterior open bite, have significantly lower masticatory and gastrointestinal digestive function than persons with a normal occlusion. (3) It has also been shown that after orthodontic treatment, there was no difference in masticatory function and gastric emptying between the treated group and the control group with normal occlusion. (3) Given the patients malocclusion and the likelihood of significantly reduced masticatory function and digestive function, orthodontic treatment is medically necessary.
Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

According to the documentation submitted, this is the case of a patient with a history of diabetes mellitus and hypertension. The patient presented to the Emergency Department (ED) due to chest pain, and headache. The patient was admitted to inpatient telemetry level for continued evaluation, monitoring, and treatment. The patient had a cardiology consult, X-ray, intravenous (IV) Toradol, cardiac monitoring, and continuous pulse oximetry.

The insurer has denied coverage for inpatient hospital admission. In their Final Adverse Determination letter, they write that a review of the records shows that the patient could have been placed in observation under monitoring. The patient could have had an evaluation by professional(s), had testing and been treated symptomatically while awaiting test results. The admission does not meet clinical criteria.

This is a patient with a past medical history of diabetes mellitus and hypertension that presented to the hospital with chest pain.  On arrival to the hospital, vital signs were stable: blood pressure (BP) 126/84, pulse 82.  Physical examination revealed no major abnormality.  12 lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST or T wave abnormalities.  Serum blood testing revealed no major abnormality.  Computed tomography (CT) chest revealed coronary artery calcium.  The patient was treated with Toradol and discharged with cardiology follow up.

This patient presented with atypical chest pain and a past medical history of hypertension. The patient's pretest probability of coronary artery disease was low (1).  Utilizing the HEART (identifies cardiac risk) score the patient was considered low risk (2).  Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score, the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days (3). Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed (3).  Using the HEART  score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all-cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated at a lower level of care.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is not substantiated.
Diagnosis: Central Nervous System/Neuromuscular Disorder/Alzheimer's Disease

Treatment: Home Health Care/Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week.

The health plan denied the requested Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week as not medically necessary. 

The health plan's determination is overturned.

The patient is a female with a history of osteoarthritis (OA), Alzheimer's and diabetes mellitus (DM). They were recently hospitalized for congestive heart failure (CHF) and aspiration pneumonia. As a result, the patient has severe limitation in activities of daily living such as weight bearing support for dressing, bathing and commode use. They have stiffness, weakness, limited range of motion, incontinence and cognitive impairment. They require maximum to total assistance, as well as oxygen treatment.
At issue is the medical necessity for the requested health service/treatment of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week.

The health plan's determination of medical necessity is overturned, in whole.

Yes. The requested health service/treatment of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week is medically necessary for this patient
Skilled nursing home health care is health care given when a person needs skilled nursing staff (registered nurse (RN) or licensed practical nurse (LPN)) to manage, observe, and evaluate care. Skilled nursing care requires the involvement of skilled nursing staff in order to be given safely and effectively. Care that can be given by non-professional staff is not considered skilled nursing care. The goal of skilled nursing care is to help improve the patient's condition or to maintain the patient's condition and prevent it from getting worse.
In this case, the patient has severe or extensive functional limitations which would substantiate the need for the requested health care services.
Orthopedic/Musculoskeletal
Inpatient Rehabilitation

Diagnosis: Septic arthritis and osteomyelitis
Treatment: Subacute rehab stay
The insurer denied Subacute rehab stay.
The determination is overturned.

This a male patient who was admitted to subacute rehabilitation for septic arthritis and osteomyelitis. The treating facility provided a letter of support for this appeal. He was admitted following treatment for septic arthritis of the left ankle and osteomyelitis of the distal tibia. He required a left ankle incision and drainage and hardware removal. The letter states that the patient would benefit from continued skilled services. He is continuing to receive physical and occupational therapy with a goal of increasing his lower extremity range of motion and strength. Further rehabilitation (rehab) will help him to improve his activities of daily living participation and require less help from others. They would like an extension of inpatient rehab care.
Therapy notes were provided as part of this review. They demonstrate that the patient showed continued improvement with ongoing therapy. His bed mobility progressed to set up assistance only from a baseline of caregiver assist. His trunk strength improved from 3-/5 to 4-/5. Dynamic standing improved from poor to fair. His wheelchair mobility improved from moderate to supervised and distance increased from 150 feet to 250 feet. He showed improvements across multiple domains.
The health plan denied coverage for an ongoing rehab stay. They stated that the patient requires a small amount of help with daily activities and walking. His pressure ulcer is getting smaller and does not require complex care. They stated that 10 additional days were authorized to help with continued improvement. At issue is the medical necessity of the subacute rehab stay.

The requested treatment is medically necessary for the patient.
The patient is being treated for rehabilitation following a surgical procedure and infection of the leg. Rehabilitation in an inpatient setting is typically continued until patients reach their maximum therapeutic potential as outcomes are maximized with intensive early interventions. The patient had a substantial decline in functional status as a result of his infection and surgery. Given his favorable prognosis for meaningful recovery of function, ongoing therapy services were recommended as medically necessary by his treating team. They were correct in this assessment, as the patient did show improvement in functional status with ongoing therapy support. The continued rehabilitation was medically necessary and reasonable for the patient.
Diagnosis: atopic dermatitis
Treatment: Dupixent
The insurer denied Dupixent. 
The health plan's determination is upheld. 

The patient is a male with psoriasis and atopic dermatitis. He also has psoriatic arthritis. He has tried and failed Excimer, Otezla, Tremfya, methotrexate, acitretin, Siliq and Taltz. He has also been on Skyrizi and Sotyktu. 

Dupixent is not medically necessary for this patient. According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the preferred medications covered by the patient's insurance plan, such as tacrolimus ointment, are effective treatments for the management of atopic dermatitis.
A Cochrane Database of Systematic Reviews for Topical tacrolimus (which is a preferred, formulary drug) for atopic dermatitis concluded that "In summary, tacrolimus ointment seems to be safe and effective for moderate to severe atopic dermatitis in children and adults".
It is noted that the patient has tried and failed methotrexate. However, the patient has no true contraindications to the other preferred, formulary medications which have been shown to be effective for the treatment of atopic dermatitis. The preferred agents, such as tacrolimus ointment, are appropriate agents for the treatment of the patient's atopic dermatitis. The formulary medications should be tried and failed prior to initiating Dupixent. Therefore, Dupixent is not medically necessary for this patient based on the evidence-based literature.
Diagnosis: Bile duct obstruction
Treatment: Continued Stay in Skilled Nursing Facility
The insurer denied: Continued Stay in Skilled Nursing Facility
The denial is upheld.

This adult female patient was admitted to an acute inpatient level of care with bile duct obstruction. She underwent exploratory laparotomy with Roux-en-Y-Hepaticojejunostomy. Her past medical history includes cardiomyopathy, depression, hypertension, panic attack, post-traumatic stress disorder (PTSD), and suicidal ideation. The patient was admitted to a skilled nursing facility (SNF) level of care for nursing and rehab services. Her level of function required moderate assist with activities of daily living (ADLs), and transfer. The health plan covered services through day #26. Services after the approved dates are being appealed. As of the last covered day, the patient was tolerating a regular diet. The patient's level of functioning had progressed to supervised with supine to sit and wheelchair; contact guard assistance with lower body dressing and toileting; and stand by assistance with hygiene. The patient is receiving pan management with oral medications.

The requested health service is not medically necessary. 

This patient was in an acute inpatient level of care for surgical treatment of bile duct obstruction. She was admitted to a skilled nursing facility level of care. As of day #26, the patient was clinically stable. She was not receiving skilled nursing care. Her level of functioning had improved to supervision, stand by, and contact guard assistance with activities of daily living. Her level of functioning did not require ongoing skilled therapy that could only be provided at a skilled nursing facility level of care. Therefore, the continued stay in the skilled nursing facility was not medically necessary.
Diagnosis: Alzheimer's Dementia

Treatment: consumer direct personal assistance service - 80 hours per week

The insurer denied coverage for in consumer direct personal assistance service - 80 hours per week

The denial is overturned

This is an elderly patient with chronic medical problems including hypertension, glaucoma and progressive Alzheimer's dementia. The patient lives with their daughter in a private residence.  The insurer approved consumer directed personal assistance services (CDPAS) 63 hours per week and the request is for CDPAS 80 hours per week, leading to an external review.

The Uniform Assessment System (UAS) was reviewed.  The patient's cognition is described as "Moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times." The patient reportedly requires extensive to maximal assistance for completing Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework, and shopping. The patient also reportedly requires maximal assistance for bathing, lower body dressing, locomotion, toilet transfer/use and ambulation. Extensive assistance is reportedly needed for personal hygiene, upper body dressing and bed mobility. Limited assistance is reportedly needed for eating. The patient is reportedly frequently incontinent of bladder and occasionally incontinent of bowel. The patient's ability to perform activities of daily living (ADLs) and self-sufficiency have declined and deteriorated, respectively, over the prior 90 days.  There have been no reported falls over the prior 90 days.

Based on the documents submitted for review, the patient's medical condition/functional deficits are substantial, progressive and unpredictable as to require the requested increased CDPAS from 63 to 80 hours/day. The letters from the patient's treating medical providers as well as from the daughter were particularly persuasive.  Again, based on the documented submitted for review, the patient's health and safety are more appropriately provided and maintained at home with the requested increase CDPAS of 80 hours/week.   

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for increase in consumer direct personal assistance service - 80 hours per week is substantiated.
Diagnosis: Low back surgery due to back and bilateral leg pain. 
Treatment: Full hospital admission. 
The insurer denied the full hospital admission. 
The health plan's determination is overturned. 

The patient is a female who presented for an elective L (lumbar)3/4 laminectomy with diskectomy. Indication for surgery was back and bilateral leg pain which failed non-operative management. The patient had left lower extremity (LLE) weakness pre-operatively. Past surgical history (PSH) was significant for prior L4-S (sacral) 1 fusion. Intraoperative, the patient experienced a small durotomy which was primarily repaired and further addressed with Duragen and Duraseal. Post-operatively, hospitalist and physical therapy (PT) services were consulted. The patient was slow to progress with PT. She required several days of therapy in order to be able to be safely discharged home. 

The inpatient hospital admission was medically necessary. Lumbar laminectomy is typically performed as an outpatient. Unfortunately, as can happen in surgery, this patient experienced intra-operative and post-operative challenges such as durotomy and extensive physical therapy. The patient had pre-operative weakness in her left lower extremity (LLE) which can slow down physical therapy progress. Given the patient's need to remain in the hospital for more than 2 midnights, her appropriate level of care would be inpatient. The patient was not able to be safely discharged prior to postoperative day (POD) 7. Her care could not have been rendered at a lower level of care for the duration of her stay.