Persius/imr-appeals huggingface dataset:
Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Durable Medical Equipment (DME). 
The insurer denied Durable Medical Equipment Pediatric tilt wheelchair with accessories. 
The denial is upheld. 

This patient is a female with Down Syndrome and severe developmental delays whose care team is requesting a Rodeo stroller with tilt, flip-up armrests, and other accessories. Letters from the patient's occupational therapist note that the patient has poor core stability and generalized hypotonia. Per the denial letter, the following criteria must be met to approve this service: medical records detailing the condition and medical necessity of the requested service, such as impaired ability to stand and walk.
At issue is the medical necessity of Durable Medical Equipment Pediatric tilt wheelchair with accessories.

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

The requested health service/treatment of Durable Medical Equipment-Pediatric tilt wheelchair with accessories is not medically necessary for this patient.
Based on the patient's diagnosis and documentation, it is not clear that the requested items are medically necessary, as patients with Down Syndrome can have varying degrees of hypotonia. Although the occupational therapist has provided a letter stating medical necessity, there is no documentation of current status or the degree of impairment. Based on the records provided, it is not clear that the Durable Medical Equipment - Pediatric tilt wheelchair with accessories is considered medically necessary.
Therefore, the requested health service/treatment of Durable Medical Equipment-Pediatric tilt wheelchair with accessories is not medically necessary.
Diagnosis: Autism
Treatment: Occupational Therapy
The insurer denied the Occupational Therapy.
The determination is upheld.

The patient received occupational therapy with treatments focusing on improving regulation and decreasing internal distractions, improving attention/focus, and decreasing thumb sucking along with balance and coordination skills.   At issue is the medical necessity of the requested occupational therapy services.

The requested occupational therapy sessions were not medically necessary for this patient.
The patient's therapy progress note documentation does not support medical necessity for the standards of practice for occupational therapy. Occupational therapy (OT) is medically necessary when there is documentation that it is improving a patient's current condition or preventing or slowing further deterioration of the patient's condition or to help a person keep, learn or improve skills and functioning for daily living to maintain the patients current condition and all of the following elements of the plan are documented in the health care record: the services are considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition the level of complexity or sophistication or the condition of the patient is such that the services required can be safely and effectively performed only by a qualified health care provider; and the services including amount, frequency and duration are reasonable under accepted standards of practice.
No indication of objective measures of improvement are documented in the clinical information submitted nor is there any notation of activities which cannot be performed within the home exercise program environment.
Activities identified in the OT summary report which can be done by caregivers/parents include working with home exercise on the goals of : bear weight on upper extremities for 60 seconds, improving ball skills of throwing, catching, kicking with good force and gradation so he can participate with age appropriate ball activities, maintaining quadruped position.  Per the documentation the patient's mother is continuously involved in exercises and the treatment plan including carryover at home.  Therefore, the requested occupational therapy is not medically necessary.
Diagnosis: Migraine Headache
Treatment: Emgality
The insurer denied the Emgality.
The denial is overturned.

The member is a female with migraine headache disorder. She is currently treated with topiramate and Emgality for migraine prevention. The provider is requesting continuation of Emgality.

Yes, the requested Emgality is medically necessary.

The patient has tried and failed a reasonable trial of topiramate for migraine prevention. She cannot be treated with divalproex sodium, as she is a female of childbearing age. She cannot be treated with amitriptyline or venlafaxine, as she is currently treated with escitalopram. She cannot be treated with a beta-blocker (Danesh and Gottschalk), as the medical records indicate relative bradycardia (heart rate 58 and 67 at two encounters). Therefore, she has either tried and failed or has a contraindication to all of the preferred agents (Burch).

Therefore, given the above, the requested Emgality is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.
Diagnosis: Hypertension.
Treatment: Bystolic 5 milligram (mg) tab.

The insurer denied coverage for Bystolic 5 mg tab. The denial is overturned.

This patient has hypertension. Blood pressure was effectively controlled with Bystolic 10mg. The patient's doctor documents an allergic reaction to the generic form of Bystolic (nebivolol). Alternative formulary agents are documented to be ineffective in controlling blood pressure. These agents include, atenolol, bisoprolol, carvedilol, labetalol, and metoprolol. 

Based on the information provided, the formulary medication (nebivolol) is likely to cause an adverse reaction. In addition, the other formulary drugs have been documented to be ineffective. The requested drug has successfully controlled blood pressure for approximately a year and a half. Studies have demonstrated that a small number of individuals require use of name brand medications following use of generic formulations. (2) In this case the patient has been maintained on Bystolic for several years and has noted intolerance to generic formulations and inefficacy to other formulary medications. 

The requested drug is likely to be more effective than the formulary drugs.

The insurer's denial of coverage for Formulary Exception for Bystolic 5 milligram (mg) tab is overturned.
Diagnosis: Vision. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Acthar Gel. 
The denial is overturned.

The patient is a male with history of keratoconjunctivitis. The treating physician would like to prescribe Acthar gel for the treatment of the patient's eye disease. The patient has symptoms of burning and pain that interfere with his life daily. He has been previously treated with Cequa, Xiidra, HydroEyes, over-the-counter (OTC) artificial tears, Lotemax, serum drops, and punctal plugs but remains symptomatic. The subject under review is the medical necessity for the Acthar gel.

The health plan's determination is overturned.

This patient has been on multiple medication including serum drops and punctual plugs without improvement. Acthar would be medically necessary and appropriate as the next step in the treatment of this patient.

Acathar gel has been Food and Drug Administration (FDA) approved for patients with severe acute and chronic allergic and inflammatory processes involving the eye and its adenoma. This includes keratitis, iritis, iridocyclitis, diffuse posterior uveitis and choroiditis, optic neuritis, chorioretinitis, and anterior segment inflammation. This patient has a history of keratoconjunctivitis which has been refractive in its treatment. The patient has been on multiple medication including serum drops and punctual plugs without improvement. Acthar would be an appropriate as the next step in the treatment of this patient.
Diagnosis: Diabetic ketoacidosis (DKA).
Treatment: Inpatient admission.

The insurer denied coverage for an inpatient admission.  The denial is overturned.

The patient has a history of (H/O) IDDM (insulin dependent diabetes mellitus), hypertension (HTN), and hyperlipidemia (HLD).  He presented to the emergency department (ED) with complaint of (C/O) shortness of breath (SOB), and R (right) sided chest pain (CP). The patient was reportedly non-compliant with his Diabetic meds. The patient also C/O a productive cough.

Vital signs at presentation were as follows: Temperature 37.3 F (Fahrenheit), Heart Rate 107, Respiratory Rate 18, Blood Pressure 169/81 mm Hg (millimeters of mercury), and Oxygen (O2) saturations 89%. The patient was tachypneic and in some distress. Physical exam revealed Rhonchi and decreased BS (bowel sounds) bilateral (B/L). The patient also had a diabetic foot ulcer and infection.

White blood cell count (WBC) was 12.8K (thousand). The patient had a BG (blood glucose) of 479 and the HbA1C (glycated hemoglobin test) was 16.7 Anion Gap was 16 B-OH (Beta-Hydroxy) butyrate was 5.5 pH (potential for hydrogen) 7.31/PCO2 (carbon dioxide) 33.

Chest x-rays revealed (CXR) revealed B/L airspace disease.

The patient was treated with intravenous (IV) fluids and IV insulin 1 dose was given in the ED (emergency department). The patient was also treated with Solumedrol, BD (bronchodilator) and BS (broad spectrum) antibiotics (Abx). 

Repeat Labs came back later that evening which revealed that AG (albumin/globulin) had increased to 17. His BG was still elevated to 453.

The patient had decreased serum HCO3 (bicarbonate). At this point the patient was admitted to the intensive care unit (ICU) for management of his diabetic ketoacidosis (DKA). The patient also had sepsis secondary to pneumonia and the Diabetic foot infection. The patient was also diagnosed to have a chronic obstructive pulmonary disease (COPD) exacerbation.

This patient was acutely ill with life threatening DKA, pneumonia (PNA), diabetic skin and soft tissue infection and a COPD exacerbation. Based on above, it was appropriate to admit this patient to the hospital for active treatment and very close monitoring. This patient was not stable to be treated in any other setting.

This patient decided to sign out against medical advice (AMA), which was not in any one's control. He was not stable at the time he absconded from the hospital.

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

The insurer's denial of coverage for inpatient hospital admission is overturned. Medical Necessity is substantiated.
Diagnosis: Abdominal pain
Treatment: CT (computed tomography) scan
The insurer denied Computed Tomography (CT) of Abdomen and Pelvis . 
The health plan's determination is overturned. 

The patient is a female with history of recurrent diverticulitis and sigmoid colon resection, and lysis of adhesions. She has had constipation. She presented with significant tenderness and pain in the left lower quadrant of the abdomen. She had ongoing abdominal pain (persistent for a month).

Computed Tomography (CT) of Abdomen and Pelvis is medically necessary for this patient.

Given that a cause for ongoing abdominal pain has not been definitively determined in the patient, and CT scan has a high sensitivity for several serious etiologies for abdominal pain that cannot be discovered by physical examination or more limited imaging examinations, and given that the patient has a history of diverticulitis and may now have persistent diverticulitis or complications of diverticulitis such as abscess, the requested CT scan is medically necessary in this case.
Diagnosis: Asthma
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay. 
The determination is upheld. 

This is a female child with a medical history significant for moderate persistent asthma, eosinophilic esophagitis, food allergies, allergic rhinitis, and eczema who presented to the emergency department (ED) with a one-day history of increased work of breathing. She had been seen in the ED earlier that day, treated with DuoNebs and steroids for an asthma exacerbation, and discharged home. She returned to the ED for persistent wheezing unresponsive to nebulized albuterol at home. 
The examination was significant for non-toxic appearance, moist mucous membranes, tachycardia, decreased air movement, wheezing, and tachypnea. She was able to speak in full sentences, with non-focal neurologic exam. 
She was treated with magnesium, two DuoNebs, and a normal saline bolus. She was subsequently admitted because she remained symptomatic. Admission orders included continuous cardiopulmonary monitoring, regular diet, maintenance intravenous (IV) fluids, albuterol 2.5 milligrams (mg) every three hours, continued home medications (cetirizine, Singular), continued oral steroids. 
She remained hemodynamically stable throughout the hospital stay with no need for supplemental oxygen. Albuterol was gradually weaned to every four hours. She tolerated her other medications as well as her diet.  She was deemed stable for discharge to pursue allergy testing. At issue is the medical necessity of an inpatient stay. 

The inpatient stay was not medically necessary. 

Asthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production. Gas exchange abnormalities are due to ventilation/perfusion mismatch, as a result of atelectasis and airway over-distention. Status asthmaticus is said to occur when the patient fails to respond initially to bronchodilators and other medications administered in an emergency department (ED) setting. Asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. 
In the ED, primary management strategies include correction of hypoxia, rapid improvement of airflow obstruction, and prevention of progression. This is achieved with supplemental oxygen, bronchodilators, and steroids. Fluid hydration may also be necessary. For patients with moderate to severe exacerbations that do not respond to such intensive therapy in the ED, admission is necessary. 
This female child with a complex and significant history including moderate persistent asthma presented to the ED for the second time in one day. She remained symptomatic despite aggressive care in the ED and was admitted for ongoing treatment. While it was reasonable and appropriate to monitor this patient in the hospital to provide ongoing care, she was overall hemodynamically stable with no need for supplemental oxygen and no evidence of impending respiratory failure. She did not require acute inpatient admission and could have been safely managed at lower level of care.
Diagnosis: Shortness of breath
Treatment: Hospital admission
The insurer denied coverage for an inpatient admission.
The denial is upheld.

This is a patient with a history of Asthma presented to the emergency department (ED) with complaint of (C/O) shortness of breath (SOB) with productive cough and wheezing. The patient had used her inhalers at home but did not feel better so came to the ED.

Vital signs at presentation included: Temperature 98.1 degrees F (Fahrenheit) , Heart Rate 99, Respiratory Rate 18, Blood Pressure 126/72, oxygen (O2) saturation 98 % on Room Air. White blood cell count (WBC) was 9.7 K (thousand) Hb (hemoglobin) 14.3, electrolytes were within normal limits (WNL), oxygen saturation was 92-93 % on room Air, chest x-ray was negative. COVID-19 (coronavirus disease 2019) and Influenza were negative.

The patient was noted to have bilateral (B/L) wheezing and was given Decadron intravenous (IV) 10 mg (milligrams), Magnesium sulfate, and DuoNebs. She did show improvement but as she was still wheezing, she was admitted to the hospital with acute exacerbation of asthma. Per the history and physical (H&P), the patient was in no acute distress (NAD), was afebrile, and hemodynamically stable. A lung exam showed a bilateral wheeze. The patient was switched to Solumedrol 60 mg and continued on nebulizers and Doxycycline. 

The patient was in no distress with stable vital signs: Temperature 98 degrees F (Fahrenheit), Heart Rate 91, Respiratory Rate 17, Blood Pressure 113/65, oxygen (O2) saturation 98% on Room Air. No evidence of CO2 (carbon dioxide) retention.

The patient was not hypoxic, was hemodynamically stable, not using accessory muscles and was speaking in full sentences. No pneumonia (PNA) on the CXR (chest x-ray). The patient was stable to be switched to oral steroids and other medications. The patient could have been treated under observation status for up to 48 hours. She remained stable after admission and did not need acute inpatient hospitalization.

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 the hospital admission is not substantiated.
Diagnosis: Spasticity at the ankle
Treatment: Durable Medical Equipment -flexion/extension device
The health plan denied the Durable Medical Equipment as not medically necessary. 
The health plan's determination is upheld. 

This is a male who is a partial spastic tetraplegic. He is status/post (s/p) C3-T1 decompression and fusion. He has spasticity and is requesting an Ankle Dorsiflexion Dynasplint for range of motion (ROM) and stretching.

The ankle Dynasplint is not medically necessary for this patient with spasticity at the ankle. 

Standard of care for spasticity in the spinal cord population includes toxin injection with aggressive range of motion and splinting. Treatment for this condition includes a toxin injection and an ankle-foot orthosis (AFO)/multipodus boot.
Diagnosis: Gastroesophageal reflux disease (GERD)
Treatment: Transoral incisionless fundoplication (TIF)
The insurer denied transoral incisionless fundoplication (TIF).
The determination is overturned.

The patient has gastroesophageal reflux disease (GERD). He has failed proton pump inhibitor therapy for multiple years, as well as pantoprazole 40 milligrams (mg) daily with famotidine 40 mg daily. An esophagogastroduodenoscopy showed unremarkable esophagus, a small hiatal hernia, patchy gastritis, gastric polyps, and unremarkable duodenum; gastroesophageal junction biopsies showed mild chronic inflammation. Esophageal manometry was normal. At issue is the medical necessity of transoral incisionless fundoplication (TIF) for the treatment of GERD.

The requested TIF is medically necessary. The efficacy of TIF using the EsophyX device has been studied in a meta-analysis including 3 randomized controlled trials (including 233 patients at 3 years), with findings of improved esophageal potential hydrogen (pH), decreased proton pump inhibitor utilization, and improved quality of life compared with proton pump inhibitor therapy of sham treatment [1-4]. The American College of Gastroenterology (ACG) guidelines for the treatment of GERD state that "We suggest consideration of transoral incisionless fundoplication (TIF) for patients with troublesome regurgitation or heartburn who do not wish to undergo anti-reflux surgery and who do not have severe reflux esophagitis (LA grade C or D) or hiatal hernias greater than (>) 2 centimeters (cm)." In this case, the patient does not have severe reflux esophagitis or hiatal hernia larger than 2 cm [5]. Additionally, the patient has attempted therapy with a proton pump inhibitor, as recommended by ACG guidelines, without improvement in symptoms and concurrent gastroesophageal junction inflammation on endoscopic biopsies. For these reasons, the use of transoral incisionless fundoplication is supported as medically necessary for the treatment of this patient's GERD.
Diagnosis: Coronary Artery Disease
Treatment: Inpatient day
The insurer denied coverage for inpatient day
The denial is upheld.

This elderly woman presented to the hospital for elective cardiac catheterization due to worsening of dyspnea on exertion. Past medical history was significant for hypertension and diabetes mellitus. She was noted to have a positive stress test. Cardiac catheterization was performed and revealed a left anterior descending artery stenosis. A drug eluting stent was successfully deployed. There were no perioperative complications, and the patient was discharged the following day. 

This patient presented for elective percutaneous revascularization. She underwent an uncomplicated procedure, and a drug eluting stent was placed in the left anterior descending (LAD) artery. She was discharged the following day. Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital (Reference 1-4). Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care (Reference 4). In conclusion, inpatient admission was not medically necessary. The patient could have been managed at a lower level of care.

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

The insurer's denial of coverage for the inpatient day is upheld. Medical Necessity is not substantiated.
Diagnosis: Gynecomastia.
Treatment: Breast Reduction and Suction Assisted Lipectomy, Trunk (Removal of Extra Breast Tissue).
The insurer denied: Breast Reduction and Suction Assisted Lipectomy, Trunk (Removal of Extra Breast Tissue).
The denial is upheld.

This patient is a young adult male who presents with complaints of fullness behind both nipples since adolescence. The patient reports developing breast tissue just behind the nipples on both sides which caused projection. He has lost weight and has begun to work out in the gym frequently with a continued projection of the nipple. He reports that when he is cold and he has hardening of the nipples he has a normal profile. He would like to surgically correct the shape and fullness of his nipple. The patient denies taking prescription medications. He denies taking illicit drugs including marijuana. He denies testicular masses. Mastectomies and liposuction are planned.

The proposed treatment is not medically necessary.
The mastectomies are cosmetic. The patient has gynecomastia, but the records do not document any health or functional problems caused by the enlarged breasts. There is no documentation of an endocrine evaluation and exclusion of an endocrine cause. There is no documentation of a concern for a breast malignancy and there are no diagnostic studies provided. The records do not document a need for treatment with analgesics or problems with activities of daily living due to his enlarged breasts.  

Gynecomastia is a benign condition that does not cause health or functional problems.  According to a review article from the Mayo Clinic, "Overall, gynecomastia is a benign condition and is usually self-limited. Over time, fibrotic tissue replaces the symptomatic proliferation of glandular tissue and tenderness resolves. If the appropriate work-up does not reveal considerable underlying pathology, reassurance and periodic follow-up are recommended...Patients with gynecomastia have a favorable prognosis. These patients present with 2 main concerns: ruling out breast cancer and cosmetic correction. The first concern is adequately addressed by following the appropriate diagnostic evaluation. Breast cancer is rare in males, representing less than 1% of all cases of breast cancer; only 1% of mammograms in men reveal breast cancer.  Therefore, the decision to treat and the choice of treatment should be based on the degree to which this condition has affected the quality of life and mental health of patients and on their desire for cosmetic correction."  

The records do not provide any evidence of concern regarding breast cancer. The procedure will primarily improve appearance and self-esteem and therefore is cosmetic and not medically necessary. Observation, reassurance, and use of analgesics as needed are reasonable management approaches for this condition. The patient is likely to derive emotional benefits from the surgery, but his physiologic health will not be improved.