Persius/imr-appeals huggingface dataset:
Diagnosis: CAD
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

This was an elective, scheduled, uncomplicated percutaneous intervention on a patient with known anatomy. Both guidelines and standard community practice would recommend that it is safely performed in an outpatient setting. In this case, there was never any hemodynamic instability, angina, ischemic changes, or an unstable situation. While the patient did complain of a brief episode of dyspnea, his CXR was negative, his ABG was normal, O2 saturation was 98%. The only treatment that was recommended was an inhaler. 

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. 
  
The letter of appeal was carefully considered, but it offered no evidence to support an inpatient level of care. The only cardiac care post-PCI that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of ischemia post procedure.  While there was always a potential for an adverse event (and in this case a very low probability), one did not happen, and no actual treatment was added. The procedure was electively scheduled and performed without complication, and the recovery essentially uneventful. The patient's SOB was brief, reversible and did not require significant intervention. There was no requirement in any part of this admission that required acute level of care.

Milliman criteria requirements were not fulfilled, as there was never any evidence of ACS (acute coronary syndrome) present. Neither triple vessel CAD nor being a smoker requires an inpatient level of care. There was no evidence of "inadequate physiologic recovery." There is no evidence to support that the patient's potential for a complication required an inpatient level of care. Since all testing and therapy that were provided would have been appropriate, safe and guidelines consistent in a lower level of care, the inpatient level of care was thus not medically necessary.

The denial explanation was consistent with guidelines and usual community care.
The patient is a male with systemic juvenile idiopathic arthritis who is prescribed Kineret. The health plan denied it as not medically necessary as he did not try the preferred medications, Ilaris and Actemra. The health plan's determination is overturned.  The Kineret is medically necessary for the patient.

Anakinra, along with Ilaris and Actemra are considered standard of care treatments for SJIA however, the American College of Rheumatology, in its most recent guidelines, recommends anakinra as initial therapy or for continued disease activity following NSAIDs as in this patient's case.
Diagnosis: Suicide attempt, hallucinations.

Treatment: Inpatient admission, evaluation, and medication management

The insurer has denied inpatient mental health. That denial was modified.

The patient was admitted to inpatient mental health treatment due to a suicide attempt by overdose of Mirtazapine. She had reports of command auditory hallucinations suicidal in nature, persecutory delusional thinking, depressed mood, feelings of hopelessness, helplessness, and worthlessness, psychomotor retardation, irritable mood, poor activities of daily living (ADLs), and she had a past reported suicide attempt. She was initially admitted to telemetry after the suicide attempt.  She had diagnoses of Schizoaffective Disorder and Major Depressive Disorder.  She took Abilify.

The insurer denied coverage for continued inpatient mental health treatment in this hospital as not medically necessary.  They stated that she was stable with no self-harm or suicidal thoughts, had no mention of active psychiatric issues, was responsive to treatment, and they recommended a less restrictive level of care.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with past suicide attempts are at high risk for suicide and past suicide attempts are the single most reliable indicator of suicide.  It also states that patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital.  This patient was considered a high risk patient and required continued inpatient acute hospital treatment in the hospital as she had three reported suicide attempts in 2018 and was considered a high risk for suicide.  She also continued with psychotic and depressive symptoms during part of the denial period.  

The documentation supports the need for approval in part.
Diagnosis: Benign prostatic hyperplasia
Treatment: Acute Inpatient Hospital Admission

Summary:
Care after an uncomplicated TURP can be provided at a lower level of care.  Because there were no signs of complications, infection, excessive bleeding, or instability an acute inpatient level of care was not necessary.  The care of his co-morbid conditions was routine.  An observation level of care was appropriate
Diagnosis: Endocrine/Metabolic/Nutritional (Morbid obesity), Digestive System/ Gastrointestinal (GERD), Respiratory System (Sleep apnea)
Treatment:  Surgical Services (Stomach surgery for weight loss)

Summary: This patient has a history of morbid obesity, migraine, asthma, gastroesophageal reflux disease (GERD) without esophagitis, sleep apnea, and diabetes mellitus. Per the office note with the Bariatric Surgeon, the patient has completed all preop evaluation for bariatric surgery and is ready to proceed. The patient's body mass index (BMI) was 38.8. Per the note for the initial bariatric evaluation, the patient had a BMI of 38 and had diabetes diagnosed two to three years ago. She has had numerous weight loss attempts. The Pulmonologist/ Sleep Medicine specialist noted in a letter that the patient has morbid obesity and symptoms suggestive of obstructive sleep apnea (OSA). Her exam is significant for morbid obesity and a crowded oropharynx. The Home Sleep Apnea Testing (HSAT) showed mild OSA with an apnea hypopnea index (AHI) of 7/hr. She was not contraindicated for surgery, although deep extubation should be avoided and anesthesia consultation prior to surgery should be done. The Dietitian saw the patient for nutrition consultation and found that the patient has made significant attempts at non-surgical weight loss using a variety of methods. The patient was counseled regarding preop diet, as well as the progression of food after surgery. It was noted that the patient is required to follow up with the dietician or nutritionist both pre and post-surgery for further dietary guidance and behavioral change counseling, and it was also recommended that the patient attend support groups and educational workshops when available. Labs showed that the HbA1c was 6.2, which is considered pre diabetic. The patient was seen by the Cardiologist for preop evaluation for coronary artery disease (CAD) and was found to have no contraindication for surgery.

The insurer has denied coverage for stomach surgery for weight loss. The denial was upheld.

Based upon the records provided, the patient does not meet the criteria and indications for bariatric surgery. At the most recent visit, the patient had a BMI of 39.2 and has never had a BMI greater than 40. She does not have severe sleep apnea/OSA but rather very mild OSA with an AHI of only 7/hour. In fact, the Pulmonologist did not confirm that she had sleep apnea, but only that she has symptoms that are suggestive of OSA and an exam significant for a crowded oropharynx. She does not have diabetes as her HbA1C is only 6.2, which is considered pre-diabetic. Although she has undergone appropriate evaluation including psychiatric and nutrition, and has followed a medically supervised program, she does not meet the BMI criteria and she does not have significant co-morbidities. The medical necessity is not substantiated.
Diagnosis: Attention and concentration deficit; major depressive disorder
Treatment: Methylphenidate HCI 5MG
The proposed treatment is medically necessary.
The patient has a diagnosis of major depressive disorder, moderately severe and recurrent without psychotic features. He has a history of treatment refractory depression failing trials with six antidepressants: Lexapro, Zoloft, Wellbutrin, Cymbalta, Fetzima and Viibryd. He has experienced worsening episodes of depression over a ten year time interval associated with general medical illness. He is currently prescribed Luvox and Seroquel together with Xarelto, Losartan, atenolol-chlorthalidone and alprazolam. 
The patient's current mental status examination reflects depressed mood with associated symptoms of anxiety, low interest and motivation, decreased concentration and fatigue, and, motor retardation. He is well groomed with clear speech and no evidence for mood cycling or mania, thought disorder, psychosis or severe cognitive impairment. Insight and judgment are fair. He has sleep disturbance with low energy and volition associated with social withdrawal. PHQ-9 is at 14 reflecting moderate symptoms of depression.
Methylphenidate 5 mg bid is prescribed for augmentation of his major depression with the treatment goal of improvement in functioning and symptoms of the major depressive disorder. Coverage for methylphenidate (Ritalin) to address the treatment-resistant depression is requested to address these target symptoms of low energy, motivation and mood, and to augment any other antidepressant medications. There are no other documented diagnoses of substance use disorder; or, co-morbid psychiatric diagnoses.
The use of stimulant medications including methylphenidate (Ritalin) is considered a clinically appropriate and effective augmentation strategy for the treatment of major depressive disorder in patients who are refractory/resistant to treatment with antidepressant medications. Moreover, the patient in this case has a likelihood of demonstrating a response to the current regimen that includes the starting dose of 5 mg bid with regard to symptoms of fatigue, low interest and motivation, and decreased concentration or focus, as well as the core symptoms of major depressive disorder.  The requested treatment has a reasonable expectation for improvement and/or maintenance treatment of major depressive disorder in a patient with treatment refractory depressive disorder and comorbid general medical illness associated with symptoms of low energy, fatigue, mood and motivation in keeping with the scientific literature concerning treatment refractory depression and medication augmentation strategies. the requested benefit of methylphenidate to address symptoms of moderately severe and recurrent major depressive disorder and/or to augment the antidepressant medication regimen is considered medically necessary in this case scenario, in keeping with prevailing standards of professional practice.
The patient was admitted from the emergency department for anemia and worsening renal failure with a plan to initiate dialysis. At issue is the medical necessity of the inpatient stay. The health plan's determination is upheld. The patient did not have evidence of an acute process contributing to the progression of the renal disease that required inpatient treatment.
Diagnosis: Preterm rupture of membranes, vaginal bleeding
Treatment: Inpatient admission
The inpatient admission was medically necessary.
Regardless of the duration of labor or hospital stay, inpatient level of labor and delivery care with associated nursing and other support is required for patient safety, pain relief, and psychological support that is not available from outpatient surgery resources for patients laboring and delivering at any gestational age.  In all cases, but especially in the circumstance of a perinatal demise and associated need for grief support and compassionate caregiving, specialized nursing support is needed for both physical and psychological wellbeing that would not be possible in an outpatient surgical unit.  Patients in this situation often are at risk for numerous hemorrhagic, infectious, and obstetrical complications that require specialized nursing and access to specialized hospital resources.  Therefore, this care should be provided in a standard labor and delivery environment and is medically necessary.
This is a patient with a medical history significant for depression, hyperlipidemia, fatigue, gait mobility, hypertension, osteoarthritis, obesity, unspecified pain and stress incontinence.  The health plan's determination of medical necessity is upheld.  The amount of hours provided are adequate to meet this patient's medical needs for the required services. An increase in service hours is not medically necessary for a decrease in endurance.
This is a patient who presented to the emergency department (ED) with acute onset abdominal pain, nausea and vomiting (2-days duration).  The past medical history was significant for morbid obesity.  The heart rate at the time of presentation was elevated at 107 beats/minute.  The abdomen was tender and distended.  The white blood cell count (WBC) count was elevated at 13.6 thousand (K).  The patient was evaluated with a computed tomography (CT) scan of the abdomen and pelvis that showed dilated and edematous bowel and mesentery.  The health plan's determination of medical necessity is overturned in whole.
The submitted records support that this patient presented with an acute onset of abdominal pain, nausea and vomiting.  She had a leukocytosis of 13.6 K and pathology identified on a CT scan that indicated possible bowel obstruction.  She was monitored with daily examination and follow up lab assessment.  She underwent a colonoscopy on 12/6/18.  Her condition did gradually improve over 72 hours.  On 12/7/18 she reported less pain and there was improvement with regard to the abdominal pain.  Inpatient admission for the condition of intestinal obstruction was consistent with medical standards, as the period of inpatient confinement was anticipated to last more than 2-days.
Other
Prescription medication

This is a patient with ankylosing hyperostosis (Forestier), site unspecified spondylopathy, unspecified vs. inflammatory disease. The patient also has gout. The patient has tried and failed Motrin, ibuprofen, Aleve, naproxen and Enbrel. Patient has also tried physical therapy (PT) and does stretching exercises. Per chart review patient is human leukocyte antigen B27 and inflammatory markers are normal, new findings of (sacroiliac)si joint (jt) ankylosis/sacroiliitis. The health plan's determination of medical necessity is overturned in whole. The patient has tried and failed conservative treatment with Motrin, ibuprofen, Aleve, naproxen and PT. The patient has even tried Enbrel. The provider believes there may be an inflammatory component to the back pain, which is why the provider tried Enbrel and is now requesting Cosentyx. Per chart review, the patient has sacroiliitis in which case a trial of Cosentyx is a reasonable next step in the treatment of this patient. According to the literature, in patients with AS who often have sacroiliitis, "secukinumab at a subcutaneous dose of 150 mg, with either subcutaneous or intravenous loading, provided significant reductions in the signs and symptoms of ankylosing spondylitis at week 16" (3).
The patient and her spouse are carriers of Tay-Sachs disease. They are requesting in-vitro fertilization with preimplanatation genetic testing to prevent having a child born with the disease. The health plan has denied the IVF as not medically necessary. The health plan's determination is overturned. IVF is medically necessary for this patient. If services are not provided, the couple have a 25% chance of having a child with a fatal childhood disease. With the testing the chances of having a child with Tay-Sachs are less than 1%. IVF with PGT-M is in accordance with accepted standards of medical practice for this patient's circumstances.
This is a patient with a history of a heart murmur who presented with difficulty breathing, who was well until 2 days prior to presentation when he developed a cough and difficulty breathing. During that night and into the early morning he had 2 episodes of post-tussive emesis. He continued to worsen throughout the following day, when his mother noted that he continued to have respiratory symptoms as well as a fever. He was brought in for evaluation and was diagnosed with croup. The health plan's determination of medical necessity is overturned.  The patient had worsening symptoms despite appropriate therapy as an outpatient, and continued to have stridor and increased work of breathing after receiving appropriate and intensive treatment in the emergency department. He required several doses of racemic epinephrine, as well as intravenous fluids to maintain his hydration status in the setting of multiple episodes of posttussive emesis.
Diagnosis: Painful breast implants
Issue under review: 15734 - Muscle, myocutaneous, or fasciocutaneous flap; trunk, 19371 - Periprosthetic capsulectomy, breast

Determination: 
The surgery is not medically necessary.

The patient has periprosthetic capsular contracture, which is a known complication of breast implants.  A study by Dancey et al found a 26.9% incidence of capsular contracture following breast augmentation surgery.  The original procedure was for cosmetic purposes.  Capsular contractures typically cause discomfort and pressure in the breast, but have no long-term health risks if untreated.  
The standard of care indicates that when implants are placed for reconstructive purposes, then treatment of these complications should be a covered service. However, in this case, the initial procedure of breast augmentation was a strictly a cosmetic procedure.  Using the American Society of Plastic Surgeons (ASPS) position paper on reoperation for implants placed for cosmetic augmentation, the medically necessary conditions for reoperation are broken or failed implant, infection, implant extrusion, siliconoma or granuloma, interference with the diagnosis or treatment of breast cancer.   The ASPS position paper goes on to say that insurance carriers, "respond thoughtfully and with compassion on an individual basis," for several other conditions, including, "mastodynia (painful breasts) and medically significant capsular contracture (capsular contracture that produces pain, disfigurement and/or interferes with mammography)." 
Capsular contracture is a benign condition. Although contractures can be painful, they do not pose a health risk or danger.  The surgeon's note indicate that her breasts are soft and, based on this description and the photos, she does not have Baker IV capsular contracture.  Surgery will make the patient more comfortable and will improve the appearance of her breasts, but it is not necessary to prevent a disease or illness or to treat a functional problem.
Diagnosis: Substance abuse disorder
Treatment: Inpatient detox

Summary:
The patient is an adult male who presented with a request for detoxification services. The patient reported that he was using alcohol, cannabis, and opioids (heroin), as well as a past history of sedative-hypnotic-anxiolytic use (benzodiazepine) and tobacco. 

The proposed inpatient stay and detoxification treatment and other medical services could have been safely and effectively provided at a lower level of care. The treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of PTSD and depressive disorder and despite ongoing substance use disorder with multiple substances of abuse. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or other emotional disturbances that would have warranted an inpatient level admission and detoxification treatment. There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatment and rehabilitation substance use treatment recently with discharge from another facility five days prior to admission. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with an extensive past history of multiple treatment episodes. Thus, an inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.
Diagnosis: Cholecystitis
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary. 

The timing of cholecystectomy in patients presenting with acute cholecystitis has been under intense investigation, with "early" cholecystectomy variably defined in the literature as gallbladder surgery performed within three, seven, or 10 days of symptom onset, and "delayed" cholecystectomy as that performed seven or 45 days, or six weeks, after initial diagnosis. Evidence from large database reviews and randomized trials generally associates cholecystectomy performed early during the initial hospitalization with better outcomes.

After an uncomplicated elective laparoscopic cholecystectomy, patients can drink clear liquids once awake from anesthesia, and their diet can be advanced as tolerated.

Most otherwise healthy, reliable patients with good home support can leave the hospital within six hours after surgery. Cochrane reviews have found no significant differences for important clinical outcomes for patients discharged the same day versus admitted overnight following laparoscopic cholecystectomy. A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, which included 15,248 patients older than 65 years of age who underwent elective laparoscopic cholecystectomy, identified congestive heart failure, American Society of Anesthesiologists class 4, bleeding disorder, and renal failure requiring dialysis as significant independent predictors of inpatient admission and mortality.

The patient should have no activity restriction unless the umbilical incision was particularly large. Then, limited heavy lifting for a few weeks is advisable. Most patients are able to return to work within one week. Patients follow up in clinic two to four weeks after their operation.

Most patients have some abdominal pain that resolves within two to three days after surgery and can be managed with analgesics. Occasionally, patients have referred shoulder and neck pain from the CO2 insufflation causing diaphragmatic irritation.

In this case, the patient was young, healthy, with no comorbid conditions. In addition, she was not septic, had a normal white count and had a routine surgery without untoward events. She recovered as expected, and she exhibited no signs or symptoms of any complications in the immediate postoperative period.