Persius/imr-appeals huggingface dataset:
Diagnosis:  Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder, Disruptive Mood Dysregulation Disorder, Conduct Disorder, and Generalized Anxiety Disorder

Treatment:  Registered Nurse (RN) assessment for recertification of Consumer Directed Personal Assistance Services (CDPAS)

The insurer has denied Registered Nurse (RN) assessment for recertification of Consumer Directed Personal Assistance Services (CDPAS).  The denial was upheld.

The patient is a male child with diagnoses of ADHD, Oppositional Defiant Disorder, Disruptive Mood Dysregulation Disorder, Conduct Disorder, and Generalized Anxiety Disorder.  The patient is prescribed Seroquel, Clonidine, and Methylphenidate.  The request was for RN assessment for recertification of CDPAS.  It was reported that the patient could not self-administer medications, needed reminders and redirections to accomplish daily tasks and activities, did not cope well when frustrated or angry, had run away from the classroom, and had a history of throwing objects and pushing students.  It was stated that a personal aide could help manage behaviors.

The insurer denied coverage for RN assessment for recertification of CDPAS.  It was reported that he had this service for 41 1/2 hours from late 2018 to mid-2019.  

This reviewer agrees with the decision to deny coverage for RN assessment for recertification of CDPAS.  The Department of Health reports that personal care services (PCS) helps people with everyday tasks including activities of daily living or household tasks.  It also states that personal care attends to the physical needs of people disabled or otherwise unable to take care of themselves.  Such activities of daily living (ADLs) include bathing, showering, management of bodily fluids, toileting, feeding, ambulating, transferring from bed to chair or wheelchair, or in and out of the tub or shower, grooming, taking care of teeth or mouth, housekeeping, or meal preparation.

The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Attention Deficit Hyperactivity Disorder does not mention personal care assistance services as a standard for treatment.  It mentions pharmacotherapy, and also behavioral therapy and parent training as standards of treatment.  This service is not indicated for reminders and redirections to accomplish daily tasks and activities; therefore, it is not medically necessary for this child. 

As a result, uphold the previous decision and deny coverage for RN assessment for recertification of CDPAS.  The health care plan acted reasonably and with sound medical judgment and in the best interests of the patient.

Based on the above, the medical necessity for the RN assessment for recertification of CDPAS is not substantiated.  The insurer's denial is upheld.
The patient  was admitted to the hospital and discharged the following day. The patient was admitted for diagnostic evaluation of episodes of jerking of the  body which had started 1 week prior to admission. The movements were initially left sided but had been bilateral for the previous 2 days. They decreased with activity and did not occur during sleep. There was no associated loss of consciousness, urinary incontinence, tongue biting or post-ictal confusion. The patient dropped items that they were  holding during an episode.The patient was admitted to the hospital for a diagnostic workup which included an magnetic resonance imaging (MRI) brain, video electroencephalogram (EEG) telemetry, lumbar puncture, blood and urine testing. The health plans determination of medical necessity is  overturned in whole. the requested health service/treatment of the inpatient hospital stay was medically necessary for this patient.
 The inpatient stay was medically necessary, and met the criteria for Inpatient Admission for Neurology under the Milliman Care Guidelines  Health Inpatient & Surgical Care,  which states:
"Hospital admission is needed for appropriate care of the patient because of 1 or more of the following: New onset severe neurologic finding requiring inpatient care indicated by 1 or more of the following: Involuntary movements. The differential diagnosis of the onset of involuntary movements , and included seizures, movement disorder which can be due to underlying infectious or autoimmune illness, or tics.,The  inpatient admission for video EEG telemetry and diagnostic workup including lumbar puncture with sedation was medically necessary in order to correctly diagnose the paroxysmal events that the patient was exhibiting. and prevent the patient  from being inappropriately treated.
Diagnosis:  Abnormal pap smear
Treatment:  Inpatient admission
The inpatient admission was not medically necessary.
 
An outpatient observation bed is an alternate level of healthcare compromising of short stay encounters for patients who require close nursing observation or medical management.  It is an area where the patient is observed and assessed following surgery to determine a need to be admitted to the hospital as an inpatient.  
The patient in question was taken to the operating room and underwent an uncomplicated fractional dilation and curettage with hysteroscopy procedure for an abnormal pap smear of atypical glandular cells of undetermined significance.  After surgery she was not ready for discharge same day.  She required observation and nursing care to assist with her ambulation and medical management of her pain and nausea.   This could have been done in an observation status.  By post-operative day #1 the patient was ready for discharge, requiring less than a 24 hour stay.  Therefore, the patient did not require an acute inpatient stay, as the same care could have been provided under an observation status.
The patient with no significant past medical history who presented to the emergency department with complaints of nausea, vomiting, and abdominal discomfort that had been going on for 2-3 days. At the time of the initial evaluation, the patient denied fever, chills. The patient was evaluated by general surgery and was found to have no surgical cause of pain. the health plans determination of medical necessity is upheld in whole. The patient's clinical symptoms, including mild dehydration and mild electrolyte derangements, could have been handled at a lower level of care. The lower level of care was justified to ensure clinical stability and to ensure reliable oral intake. The inpatient level of care was not medically necessary for this patient, based on the severity of the patient's condition and the complexity of services.
The patient is a male who presented with vomiting and diarrhea.  He was well until the week prior to admission when he was traveling to New York after a visit to Peru.  At that time he began to have multiple episodes of emesis.  The emesis continued for 2 days before subsiding, and shortly after he developed diarrhea.  He described an average of 8 episodes of watery, non-bloody diarrhea with mucus every day.  This was accompanied by diffuse abdominal pain.
He was admitted for treatment of gastroenteritis with moderate dehydration.  He was given intravenous fluids as well as Zofran when necessary and bowel rest.  He continued to have diarrhea after admission and was started on a clear liquid diet.  His stool polymerase chain reaction (PCR) was found to be positive for rotavirus.  With hydration during the hospitalization, his electrolyte abnormalities resolved, and he was able to advance his diet.  His diarrhea had decreased, and he was stable for discharge to home.

The health plan's determination is overturned. 

This is a patient who presented with severe diarrhea after traveling out of the country. By the time of presentation he was having up to 12 episodes of diarrhea per day.  He had decreased urine output and had developed dehydration.  In the emergency department he was found to have orthostatic hypotension and abnormal laboratory values.  He required prompt initiation of intravenous hydration, as well as antiemetics as needed and close monitoring in an inpatient setting.
The decision-making at the time of admission was consistent with his young age, the presence of severe diarrhea in the setting of travel to different country, the presence of symptomatic dehydration, and the need for prompt initiation of treatment with close monitoring for potential deterioration of clinical status.
Diagnosis: ESRD, hyperphosphatemia, hypercalcemia
 
Treatment: Medication- Renvela

The insurer denied coverage for Renvela. The denial was upheld.

The patient has a history of end stage renal disease and hyperphosphatemia; also noted to have hypercalcemia and is not a candidate for PhosLo. Treating provider is requesting Renvela for her condition.

Renvela is not considered medically necessary for this patient. There is no current evidence-based literature that Renvela is safer or more effective than available preferred medications (Sevelamer carbonate, Fosrenol and Velphoro).  Based on documentation submitted, the patient has not tried and failed the preferred medications.
This is a patient with a past medical history of hyperlipidemia, osteoporosis, vertigo, who presented to the emergency room (ER) with vertigo, headache, nausea and vomiting. She had these symptoms on and off for two months, but she had worsening vertigo pulling to her left side, and a headache which localized to the right frontal area, for one hour prior to presentation. She had a National Institute of Health Stroke Scale (NIHSS) of 0 on admission.
The health plan's determination of medical necessity is upheld. She  was hemodynamically stable, without a major electrolyte abnormality, cardiac or respiratory issues, and without focal weakness, sensory changes, altered mental status, or slurred speech. The initial workup included a CT scan of the head and a CT angiogram of the head and neck was unrevealing. The neurologist's initial assessment was of a peripheral cause of the patient's symptoms as opposed to a central etiology.
According to an American Family Physician (AFP) review article on dizziness: "Evaluation focuses on determining whether the etiology is peripheral or central. Peripheral etiologies are usually benign. Central etiologies often require urgent treatment."
Diagnosis: Colitis and Campylobacter Infection

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was reversed.  

This is a young female patient who presented to the Emergency Department with complaints of worsening abdominal pain following a recent diagnosis and treatment for a Campylobacter infection. She reports a benign medical history. Vital signs on presentation included: a temperature of 37C, a blood pressure of 108/74, a pulse of 74, a respiratory rate of 18, and an oxygen saturation of 99% on room air.  The patient was given intravenous (IV) fluids and started on intravenous antibiotics (Azithromycin). She was kept nothing by mouth (NPO). A Computerized Tomography (CT) scan of the abdomen showed changes consistent with colitis. Gastroenterology consulted and recommended slowly advancing the diet as tolerated. Infectious Diseases was also consulted and recommended continuation of antibiotics. She underwent a colonoscopy. The patient remained afebrile and hemodynamically stable and was discharged to continue antibiotics as an outpatient.  
A Campylobacter infection is an important cause of acute diarrhea and may produce systemic illness, as well as other complications. Based on patient's documented failure of outpatient management, the need for IV fluids, maintaining NPO status, IV antibiotics, and a diagnostic procedure (colonoscopy), the hospital admission was medically necessary. 

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is substantiated.  The insurer's denial is reversed.
Diagnosis: Obesity
Treatment: Saxenda
The treatment with Saxenda is medically necessary.

Saxenda is a GLP1 (glucagon-like peptide-1) agonist that is used in the treatment of obesity [1-3]. The FDA label is below [4]. 

-INDICATIONS AND USAGE
Saxenda is a glucagon-like peptide-1 (GLP-1) receptor agonist indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of 
- 30 kg/m2 or greater (obese) (1) or
- 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g. hypertension, type 2 diabetes mellitus, or dyslipidemia) (1).
Limitations of Use: 
- Saxenda is not indicated for the treatment of type 2 diabetes (1). 
- Saxenda should not be used in combination with any other GLP-1 receptor agonist (1).
- Saxenda should not be used with insulin (1, 5.4).
- The effects of Saxenda on cardiovascular morbidity and mortality have not been established (1).
- The safety and efficacy of coadministration with other products for weight loss have not been established (1).
- Saxenda has not been studied in patients with a history of pancreatitis (1, 5.2). 

The patient meets accepted criteria for use of the requested medication. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

The health plan's requirement of documentation of current and prior enrollment in a comprehensive weight management program like Weight Watchers or Curves Complete is not consistent with the FDA-approved indications for Saxenda.
Diagnosis: Chest pain
Treatment: Inpatient admission
The Inpatient admission was medically necessary.

The patient presented with new onset chest pain, suggestive of unstable angina. The ECG was abnormal, consistent with ischemic changes. The presentation was in the setting of hypertensive urgency. A stress test was abnormal as well, consistent with ischemia. There was a high index of suspicion for an ACS, and a cardiac catheterization was recommended. Given the presentation, uncontrolled hypertension, as well as clinical suspicion for an acute coronary syndrome/unstable angina, he would not be an appropriate candidate for an ED chest pain observation unit.  It would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Diagnosis: Rectal bleeding
 
Treatment: Inpatient admission, monitoring

The insurer denied the inpatient hospital admission. The denial was upheld.

The patient presented with rectal bleeding. The patient initially had dizziness, but at the time of admission the dizziness had resolved. The patient was afebrile and the vital signs were stable. The abdominal exam was benign. A rectal exam did not reveal any bleeding. The hemoglobin was 13.8. The bleeding was felt to be due to hemorrhoids. The patient was treated for constipation and referred to Gastrointestinal (GI) clinic. 

Clinical indications for admission for lower GI bleeding (M-182) include having ongoing active bleeding, failure to control bleeding after a colonoscopy, coagulopathy, intestinal obstruction, and severe thrombocytopenia. The patient did not have these conditions. The patient also did not have hemodynamic instability, severe anemia, severe pain or an inability to maintain oral hydration. 

This patient had minor self-limited bleeding. The patient remained hemodynamically stable and there was no evidence of active ongoing bleeding. The patient did not meet MCG criteria for admission for lower GI bleeding. 

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is not substantiated.  The insurer's denial is upheld.
This is a child with known sickle cell disease HbSS, who presented with fever and upper respiratory infection (URI) symptoms for 3 days along with loose stools for 4 days. The patient was with a poor appetite x 1 week. Temperature maximum was 101. A chest X-ray showed questionable pneumonia. The patient was given intravenous (IV) Ceftriaxone and admitted to the hospital. The patient had multiple admissions since birth. The patient received packed red blood cells (PRBC) in the past. On this admission the white blood cell count (WBC) was 15,100 and hemoglobin (Hgb) was low at 6.4. The liver function tests (LFTs) were normal. The respiratory syncytial virus (RSV) and flu tests were negative. Blood cultures were done. On physical exam the patient was in no acute distress. The lips were mildly dry. The patient had harsh breath sounds. The Abdomen revealed a liver 2cm below the right costal margin. The registered nurse (RN) documented the child to have dry cracked lips with furred tongue and also looking weak. After admission the spleen was palpable at the left costal margin with inspiration. His WBC increased to 23.3 later on the day of admission. The patient was followed and intravenous fluids (IVF) were administered. The Hgb went up to 7.0 during admission.  The health plan's determination of medical necessity is overturned in whole. The requested health service/treatment of Inpatient Hospital Admission is medically necessary for this patient. There was a new infiltrate on X-Ray. This would be indicative of acute chest syndrome (ACS). "Clinically, ACS is defined by a new pulmonary infiltrate on chest radiograph in addition to one or more of the following: fever, tachypnea, dyspnea, hypoxia, and chest pain. ACS is a common and potentially lethal complication of sickle cell disease." This patient has had transfusion of PRBCs in the past. The low hemoglobin coupled with diarrhea, poor (PO) intake and physical signs of dehydration would also predispose the patient to crisis due to  sickle cell. IV hydration, monitoring  Intake's and Output's, (PO) intake, stool output as well as fever curve and O2 saturation would be proper care for this patient.
Diagnosis:  Issue conceiving
Treatment:  IUI
The proposed treatment with IUI was not medically necessary.

According to the American Society for Reproductive Medicine (ASRM), infertility is a disease, defined by the failure to achieve a successful pregnancy after 12 months or more of appropriate, timed unprotected intercourse or therapeutic donor insemination.  Earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after six months for women over age 35 years.

This patient was able to conceive following donor insemination but had a miscarriage.  In other words, she did not fail to conceive after six therapeutic donor inseminations, and, therefore, she does not have a diagnosis of infertility.  In the absence of such a diagnosis, treatment for infertility including the intrauterine insemination performed is not medically necessary.

The request is not medically necessary, since this patient did not have an illness, injury or disease:  She has inability to conceive due to non-exposure to sperm and due to aging a normal, natural physiological process.  The standard of care is for this patient to fail six inseminations (i.e. fail to get pregnant) before she is considered infertile and eligible for coverage of infertility services.

In summary, this patient's inability to conceive is due to natural aging and non-exposure to sperm.  She does not have a diagnosis of infertility, and the requested coverage for IUI was not medically necessary.
The patient was admitted to the hospital. The patient has a past medical history of Parkinson's disease and hypertension and presented after a syncopal episode. The patient was noted to be unresponsive and cardiopulmonary resuscitation (CPR) was initiated. Vital signs showed a blood pressure of 185/71, pulse 97, respiratory rate 18 and oxygen saturation 96%. Labs showed a white blood cell count of 7.3, hemoglobin 9.2, platelets 158, sodium 140, potassium 3.6, creatinine 0.8 and a glucose of 113. An electrocardiogram (EKG) showed sinus rhythm with frequent PVCs (premature ventricular contractions). A computed tomography (CT) of the brain showed no acute intracranial abnormalities. The patient was admitted for further management and evaluation. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient presented after a syncopal episode. Her EKG showed sinus rhythm. The head CT was negative for acute intracranial abnormalities. The patient was hemodynamically stable. An ultrasound (US) carotid showed no stenosis. No sustained ectopic foci were noted on Holter. Amantadine and Donepezil were discontinued per neurology recommendation. The patient was started on Ropinirole and Sinemet. She was also evaluated by physical therapy. No complicating events occurred during the stay. This patient's care could be provided at a lower level as there was no hemodynamic instability, pulmonary embolism, arterial dissection, acute congestive heart failure exacerbation, cardiac ischemia, atrial fibrillation or need for continuous intravenous infusion.
The patient is a male with a significant past medical history for diabetes mellitus, hypertension, chronic kidney disease, gastroesophageal reflux disease and nephrolithiasis. The subject under review is for the medical necessity of increase in personal-care service hours from 17 hours a week to 40 hours a week. The patient has currently been approved for 17 hours a week. The patient requests additional services to 40 hours a week. The health plan's determination is overturned, in part. The requested health service/treatment of Consumer directed personal cares assistance services increase from 17 to 40 hours per week is not medically necessary for this patient. However, an increase to 20 hours a week is medically necessary.
The patient's son stated that the patient needs assistance with feeding, medication, and walking. He reports the current hours are not enough, and are not adequate for bathing, dressing, toileting, and housekeeping related services. Per the Uniform Assessment System - New York Comprehensive Community Assessment Report, the patient is independent with eating, ambulates in his own home with an assistive device, and is continent of bowel and bladder. The Uniform Assessment System - New York Comprehensive Community Assessment Report recommended a total of 19 hours a week for personal care services. Based upon review of the records provided along with the documents provided in regards to nursing and aid hours, the patient would need additional hours to support basic functions such as activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The recommended increase in the personal-care hours from 17 hours a week to 20 hours a week should be sufficient to maintain activities that were noted to be medically necessary according to the documentation provided. There is no medical need for additional hours other than 20 hours a week.