Persius/imr-appeals huggingface dataset:
Diagnosis: Celiac disease and intestinal metaplasia 
Treatment: 43239 (Esophagogastroduodenoscopy [EGD] transoral biopsy single/multiple) 

The insurer denied coverage for 43239 (Esophagogastroduodenoscopy [EGD] transoral biopsy single/multiple). The denial is reversed. 

This patient is a female diagnosed with both celiac disease and intestinal metaplasia in the gastric antrum on biopsies performed during endoscopy a few years ago. The patient had been on a strict gluten-free diet and her symptoms have improved. 

According to UptoDate article on gastric intestinal metaplasia, endoscopic surveillance with gastric biopsies is advised for this patient. Literature evidence suggests that surveillance may lead to early detection of gastric cancer and improved survival. However, the optimal surveillance interval has not been fully determined. UpToDate article on "Management of celiac disease in adult" states that the consensus is that re-biopsy should be undertaken after commencing a gluten-free diet to confirm a satisfactory response to the diet. 

This patient had two conditions which required careful follow up. Both intestinal metaplasia and celiac disease diagnoses increase this patient's risk for malignancy, and a close follow-up with endoscopic monitoring was medically necessary. 

Thus, esophagogastroduodenoscopy (EGD) with biopsy was medically necessary to properly monitor and treat this patient's medical condition. 

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

The carrier's denial of coverage for procedure Code 4323 (Esophagogastroduodenoscopy [EGD] transoral biopsy single/multiple) is reversed. The medical necessity is substantiated.
Diagnosis:  Blood Disorder.
Treatment:  Pharmacy/Prescription Drugs (Pradaxa).

The insurer denied the Pradaxa.  The denial is upheld in whole.

The patient is a male with a history of chronic deep vein thrombosis.  The patient is stated to be refractory to Eliquis and Xarelto.  The patient is on an acetaminophen-hydrocodone that is stated by the provider to interact with warfarin.  Pradaxa has been recommended and is under review.

The health plan's determination is upheld. 

The patient has failed the formulary drugs Eliquis and Xarelto, and, thus, they are not appropriate for this patient.  The formulary drug warfarin has similar clinical efficacy to the non-formulary Pradaxa and is not contraindicated in this clinical scenario.  A LexiDrugs interaction check states "...Acetaminophen may enhance the anticoagulant effect of Vitamin K Antagonists.  This appears most likely with daily acetaminophen doses exceeding 1.3 or 2 grams per day (g/day) for multiple consecutive days....  Monitor for increased therapeutic effects of anticoagulants if acetaminophen is initiated/dose increased, or decreased effects, if acetaminophen is discontinued/dose decreased....  Use for more than 3 consecutive days may warrant additional international normalized ratio (INR) testing....".

Therefore, if this patient is intensively monitored, there is likely minimal risk to the use of warfarin with his current medical regimen.
Diagnosis: Chronic lung disease

Treatment: Pulmozyme

The insurer is denied coverage for Pulmozyme. The denial is upheld.  

The patient is a female who was born following a premature birth at over 30 weeks gestation.  The patient's history was significant for Pierre-Robin syndrome, seizures, developmental delay, scoliosis, dysphagia and chronic aspiration from sialorrhea. The patient had chronic lung disease and required Bilevel Positive Airway Pressure (BIPAP) when sleeping and had episodes of low oxygen saturations. The patient was treated with cough assist and Vest daily.  The patient had been treated with hypertonic saline, albuterol and Pulmozyme which the patient had been receiving twice a day for. The medical record indicates that this patient was at risk of prolonged hospitalizations prior to starting Pulmozyme and based on the impression of the patient's mother and the treating physician, the patient's respiratory condition improved on Pulmozyme.  The patient's mother indicated that the patient had clinically worsened since this patient's Pulmozyme was discontinued coverage by her insurance. The patient had been requiring additional chest physical therapy because of increased chest congestion and episodes of oxygen desaturation. The patient was seen and was not seen for a visit again until several months after.  The medical record notes that the patient had not required any Emergency Room (ER) visits or hospitalizations and she had only a few upper respiratory infection (URI) illnesses in the winter. The patient only required one course of antibiotics and treatment with 3 liters of oxygen on one occasion. 

Based on the review of the medical record and literature, Pulmozyme (dornase alfa) is not medically necessary. The patient had a complicated history of chronic lung disease and aspiration pneumonia and required airway clearance treatments on a daily basis.  There was no indication that the patient produced purulent sputum or had chronic bacterial lung infection.  There had not been a computed tomography (CT) scan or chest x-ray to document the presence of atelectasis or bronchiectasis.  The patient had not required a bronchoscopy.  In addition the medical record indicates that this patient had been stable over several months with no hospitalizations or Emergency Room (ER) visits.  The medical history does not support the need for ongoing daily therapy with Pulmozyme twice daily (BID) at home.  It is not the standard of care to prescribe Pulmozyme for lung disease related to chronic aspiration in the absence of persistent bacterial bronchitis, bronchiectasis and purulent sputum. 

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

The carrier's denial of coverage for Pulmozyme should be upheld.  The medical necessity is not substantiated.
Substance Abuse
Inpatient Hospital Stay

This patient with a past medical history of polysubstance use with alcohol, heroin, marijuana, and benzodiazepines, also on suboxone with last use several days prior, in addition to anxiety,  presented to the emergency department  with alcohol withdrawal after being evicted from friend's house. On presentation to the emergency department, patient was afebrile with blood pressure 135/96, heart rate 67, respiratory rate 18, sat 97% on room air. Exam otherwise noted dilated pupils. Labs showed white blood cell count (WBC) 8.16, Hemoglobin (HGB) 13, Platelets 304, sodium 147, potassium 4, blood urea nitrogen (BUN) 10, creatinine 0.8, aspartate aminotransferase (AST) 43, alanine aminotransferase (ALT) 31, and alcohol level of 281.3. Urine drug screen was positive for tetrahydrocannabinol (THC). Clinical Institute Withdrawal Assessment (CIWA) score was 9 in the emergency department. Patient was seen by psychiatry in the emergency department, given an initial report of suicidal and homicidal ideation and was cleared for discharge. The patient was brought into the hospital with concern for alcohol withdrawal and plans for intravenous (IV) fluids, CIWA protocol, thiamine, folic acid, and laboratory monitoring. 2 days after presentation the patient was noted to have a CIWA score of 15.  was alert and oriented. The patient wanted to leave and was deemed to have capacity to leave against medical advice. The health plan's determination of medical necessity is upheld in whole. The inpatient stay was not medically necessary. This patient presented with mild alcohol withdrawal with a CIWA of 9 in the setting of no known prior history of seizures or delirium tremens during withdrawal. It was reasonable to observe the patient on the medical unit at a lower level of care with CIWA protocol, IV fluids, thiamine and folate, and observation for the development of new symptoms such as changes in mental status. It is noted, however, that the patient remained alert and oriented throughout  hospitalization without ongoing nausea, vomiting, or inability to take oral medications. The maximum CIWA score was 15. Though ongoing observation was recommended on the last day, the patient wanted to leave and was deemed to have the capacity to leave against medical advice. It is unclear why this patient with concerns for mild alcohol withdrawal, CIWA scores of 9-15 with a normal mental status, no reports of ongoing nausea or vomiting, and without any other concurrent medical issue, required care at the inpatient level of care and could not have been safely treated at a lower level.
Digestive System/Gastrointestinal. 
Inpatient Hospital. 

Diagnosis: Abdominal Pain. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

This is the case of a child who presented to the emergency department (ED) with a 2 day history of abdominal pain. The location of pain was right lower quadrant (RLQ), and additional symptoms included anorexia. There was no fever, cough, sore throat, or vomiting. The patient was seen by the primary care physician (or provider) (PCP) who gave Zofran and sent her to the ED for further evaluation. 

The inpatient hospitalization was not medically necessary. This patient was brought to the ED for evaluation of abdominal pain. There was initial concern for appendicitis, but the ED work-up was non diagnostic. The patient's condition improved while in the ED and vital signs remained stable. He was admitted to the inpatient unit for overnight observation and re-evaluation. He was discharged home the following day. His care was appropriate for a lower level. The inpatient level of care was not medically necessary.
Diagnosis: Deep Vein Thrombosis
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission.
The denial is overturned. 
This is a male patient with a medical history of coronary artery disease (CAD), hyperlipidemia, hypertension, prior myocardial infarction (MI) and cardiovascular accident (CVA), depression, pneumonia, and bilateral lower extremity weakness. The patient presented to the Emergency Department (ED) with complaints of chest pain and leg pain. The patient described the chest pain as left-sided, sharp, stabbing, worse with smoking cigarettes, worse with cough and worse with exertion. These episodes were reported to be intermittent and last several hours at a time. The patient denied shortness of breath, lightheadedness, dizziness, headache and abdominal pain. The patient's echocardiogram was done that showed normal left ventricular ejection fraction (LVEF). The patient reported previous neuropathic leg pain; he ran out of gabapentin last week. The patient's presenting vital signs were: blood pressure (BP) 152/87, pulse 51, temperature 97.8, respirations 20, oxygen saturation 99% and BMI 34.99. The patient's physical exam noted bilateral lower extremity swelling the left being greater than the right. The patient's laboratory results included sodium 140, potassium 5.0, BUN 10, and creatinine 0.8, an initial troponin was less than 0.012. The patient's electrocardiogram (EKG) revealed sinus bradycardia at a heart rate of 49 bpm. There was left anterior fascicular block and there was asymmetrical T-wave inversion in leads III, AVF, V3-V6. These were non-specific repolarization changes. The patient's chest x-ray showed fibrosis at both lung bases. There was no acute pulmonary disease and no change when compared with imaging done. The patient was found to have an acute venous thrombosis of the left bilateral lower extremities. At the time of discharge, the patient was advised to make outpatient appointments with his primary care provider, cardiology and hematology.

This patient with a history of CAD, prior MI, CVA was found to have a pulmonary embolus with lower extremity thrombus. The multiple comorbid conditions along with the presence of PE and lower extremity thrombus argue against outpatient management. Thus, as discussed in Up to Date, while out patient anticoagulation can be used for PE, this assumes carefully selected patients. Most patients are still initially admitted as an inpatient for several days followed by long term outpatient anticoagulation.

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

Based on the above, the medical necessity for the inpatient admission is substantiated. The insurer's denial should be overturned.
Diagnosis: Breakthrough seizure
 
Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.  The denial is upheld. 

This patient is a female with a past medical history of asthma, diabetes mellitus, hypertension, and noncompliance with medication for seizure disorder.  The patient was brought to the Emergency Department by the Emergency Medical Services (EMS) with subjective complaints of severe headache, vomiting times approximately 1 hour, and the patient was noted to have left-sided facial droop on EMS arrival.  On arrival at the Emergency Department, the patient was awake and alert and continues to complain of a headache.  The patient stated she had urinated on herself and did not have neck pain or back pain.  The patient denied a fever.  The patient's blood pressure was 167/81 and her heart rate was 95.  The patient underwent imaging studies, which showed no acute pathology.  The patient had an active seizure in the Emergency Department and was treated with Ativan for the seizure.  She also received Keppra while in the Emergency Department.  A stroke was ruled out.  The patient was admitted to the general medical floor with a diagnosis of a breakthrough seizure.  The patient underwent a neurology consultation.  The patient was given a scheduled dose of Keppra and intravenous fluids, along with proton pump inhibitors and antiemetics.  The patient requested and was discharged in stable condition.

Based on MCG guidelines for Seizure, patient meets the criteria for observation care. Patient has an elevated lactate level of 2.3 and requires medication initiation.  Due to the patient's poor social condition (i.e. living in the shelter), medication should be monitored and adjusted with closing monitoring.  While the patient meets the criteria for observation status, patient does not meet the MCG guideline clinical criteria for inpatient admission.  The patient did not have hemodynamic instability or status epilepticus. Whether the patient's focal neurologic deficit (i.e. left facial droop) is new or not is questionable since the patient reported having residual left sided weakness from a stroke several years ago.  The patient's CT of the head and neck ruled out brain disorder or intracranial pathology. 

The patient was discharged within 24 hours of being started on scheduled doses of Keppra, which could have been done at the observation setting.  Thus, based on the medical records provided and MCG guideline review, inpatient admission was not medically necessary to treat this patient's medical condition. 

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

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.
Diagnosis: Hyperkalemia
 
Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial is upheld. 

This patient is a woman who had a history of Addison's disease, hyperprolactinemia, pituitary adenoma, anti-phospholipid antibody syndrome with a history of deep vein thrombosis (DVT) and pulmonary embolus, diabetes mellitus, hypertension, hyperlipidemia, coronary artery disease with stent several years ago and depression. She was sent to the Emergency Department (ED) by her Hematologist for a potassium level of 6.2 on laboratory testing; the patient was asymptomatic. Initial vital signs including a blood pressure of 98/69, a heart rate of 77, a temperature 97.4F, a respiratory rate of 18, and an oxygen saturation on room air of 98%. An EKG revealed peaked T waves, but was otherwise unremarkable. Laboratory test results included a white blood cell (WBC) count of 8.0, a hemoglobin of 10.9, a creatinine of 1.2, a glucose of 213, a sodium of 136, a potassium of 6.2, a chloride of 110, a bicarbonate of 16, and a troponin <0.012. She was treated with Kayexalate, intravenous fluids, calcium gluconate, and insulin and had an episode of nausea and vomiting while taking the Kayexalate.  

She was seen by a Hematologist who raised the issue of possible type 4 renal tubular acidosis and by an Endocrinology consultant who felt that medication compliance may have played a role. Psychiatry did not feel that she was actively depressed. She was discharged on stress doses of steroids tapered back to her maintenance doses of Florinef and hydrocortisone over a week, as well as on her other medications, which included aspirin, atorvastatin Linzess, Trulicity, bupropion, Cabergoline, Lexapro, Lantis, Novolog, metformin, metoprolol, Protonix and rivaroxaban.

There is no evidence that this patient required an acute inpatient level of care to evaluate or treat her newly noted potassium level of 6.2, which was asymptomatic, with no evidence for conduction abnormalities or arrhythmias. In addition, she did not have conditions that could contribute to a continued acute rise in potassium levels such as worsening renal function, rhabdomyolysis or significant gastrointestinal bleeding. The healthcare plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The denial of the inpatient hospital admission is upheld because there is no evidence that this patient was at risk for short term adverse cardiovascular events, based on her clinical presentation and results of testing and treatment performed in the Emergency Department.

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
This is a patient with a skeletal Class I occlusion, mild maxillary spacing and mild mandibular crowding, moderate overbite and moderate overjet. The proposed treatment is braces.

The health plan's detrmination is upheld.
The malocclusion in question does not meet criteria to be classified as handicapping and treatment would not be considered medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 14 with no auto qualifiers. Auto qualifiers include deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The patient requires a score of 26 or more for treatment to be considered medically necessary. Thus, braces are not medically necessary for this case.
Burns
Inpatient hospital stay

This is a patient who experienced a burn to the right thigh. 11 days after the initial burn, patient was found to have worsening superinfection after failure of outpatient antibiotic therapy. It was determined that the patient had a 2% total body surface area (TBSA) third degree burn. The patient was admitted for intravenous (IV) antibiotics, pain control, wound care, and plans for surgical debridement and likely skin grafting. Patient underwent tangential excision and split thickness skin graft to the thigh. The health plan's determination of medical necessity is overturned in whole. The best interest of this patient is an inpatient admission. The patient had a 3rd degree burn to 2% of his TBSA. This is a burn that started as partial thickness but progressed as an outpatient. According to the International Society for Burn Injury guidelines, any third degree burn necessitates a transfer to a burn center. Besides meeting standard practices for medical necessity, this case also meets McKesson InterQual criteria for acute adult: burns. This case qualifies with 3rd degree burns with 2-5% TBSA and need for complex burn care.
Diagnosis: Gastrointestinal and Liver Cancer. 
Treatment: Home Health Care. 
The insurer denied the requested health service/treatment of Increase in Personal Care Worker hours. 

The health plan determination is overturned. 

The patient is with a past medical history of hypertension, memory impairment, tremor, metastatic gastrointestinal stromal tumor with multiple recent hospitalizations for complications, hepatocellular carcinoma, hepatitis C, cirrhosis and biliary stricture. 

The increase in personal care worker (PCW) service to 7 days per week, 12 hours per day, 84 hours per week is medically necessary for this patient. 

The patient has a complicated past medical history. The PCW is medically necessary for helping the patient to transport and attend the medical appointments and tests. The patient does not have an informal helper. The patient has had worsening memory as documented by MMSE assessment with increased weakness related to underlying medical issues with an increased need for assistance with ADL's and Instrumental Activities of Daily Living (IADLs) as documented in multiple provider letters and in the assessment tool as compared to previous assessment. The patient lives in an apartment on the 6th floor with no elevator and the bathroom is not in the apartment, making her assistance needs for tasks of stairs, walking, locomotion, and toilet use higher than assessed. PCW service hours are not solely for supervision and safety but for assisting the patient with ADL's and IADL's. Multiple providers who care for the patient documented medical necessity to increase PCW service hours. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in the home, which is the case for this patient.