Persius/imr-appeals huggingface dataset:
The patient is an adult who presented for inpatient detoxification treatment to address severe substance use disorder with opioid and stimulant class substances of abuse. The patient has a longstanding history of heroin use with more recent use of crack cocaine. He reported a past history of severe withdrawal symptoms when attempting to curtail use, and undergone multiple detoxification and rehabilitation treatments with relapses.

The health plan's determination is overturned. The treatment of this patient's substance use disorder with detoxification and withdrawal management did require the continued structure of an inpatient level setting and 24-hour monitoring in view of the patient's clinical presentation and course of treatment. Additionally, the patient had an extensive treatment history with relapses that supported the necessity for an inpatient level of care, and presented with moderately severe withdrawal symptoms. Withdrawal symptoms were appropriately managed with tapering dosages of methadone requiring monitoring and supportive measures including the availability of nicotine replacement therapy and comfort medications.
This is a patient who presented with a subjective fever, diarrhea for three days, and vomiting for two days. Four days prior to admission he had a cough and nasal congestion which cleared up with Saline nose spray and suction. He had 4-5 episodes of diarrhea each day for the last three days prior to admission. His mother noticed some bright red streaking in his diapers with almost every diarrheal stool. She also noted some hard stool chunks mixed with loose stool. She also noted that he seemed to cry in pain with passage of stool. He also had 5 episodes of non-bilious non-bloody emesis over the past two days prior to admission. The health plan's determination is upheld. His clinical findings, described in the chart, along with his laboratory findings support a mild degree of dehydration. There was no mention of a PO trial in the emergency room after he received an IV fluid bolus as oral rehydration therapy is the recommended first line for mild to moderate dehydration. He did not meet currently accepted criteria for admission to the hospital for dehydration.
Diagnosis: Foot pain
Issue under review: Custom shoe orthotics

Determination:
The Custom shoe orthotics are medically necessary.

The treatment delivered is in keeping with reasonable acceptable standard of medical care for this condition.  Typically for plantar fasciitis, conservative care involves using custom orthotics.  The patient has been using custom orthotics for several years and they have worn out, and the treatment has already been shown to be effective for the patient.

Plantar fasciitis is typically treated with orthotics conservatively prior to more invasive treatment, such as corticosteroid injection and surgery.
This is a patient who presented to the emergency department with persistent fevers and rash. He was well until approximately 5 days prior to admission when his mother noticed a red rash starting on his legs. The rash progressed to involve his back and stomach as well as his hands and feet. He also developed fever with a maximum temperature of 103.6 degrees Fahrenheit (F). He had been receiving ibuprofen at home with little relief, and he continued to have fevers. He was tolerating some oral intake, but had intermittent episodes of decreased activity. He was seen at his primary care provider's office where there was a concern for Kawasaki disease, and he was referred to the emergency department for further care.
The health plan's determination is overturned. The patient required prompt initiation of IVIG therapy along with high-dose aspirin in an inpatient setting to treat his symptoms and prevent the potentially serious complications of Kawasaki disease. He also had a blood culture sent that was pending. He required consultation from both infectious disease and cardiology, along with cardiorespiratory monitoring with further treatment as needed. Prompt treatment with intravenous immune globulin (IVIG) reduces the prevalence of coronary artery aneurysms fivefold in patients with Kawasaki Disease. Despite its advantages, IVIG is a potentially toxic intervention, and requires careful monitoring.
Diagnosis:  Paranoid Delusions and Worsening Mania
 
Treatment: Inpatient Hospitalization

The insurer denied the Inpatient Hospitalization. 
The denial was upheld.  

This a female patient admitted to this inpatient mental health treatment in this hospital on in early 2019 due to psychotic and manic symptoms, including paranoid and grandiose delusional thinking, disorganized thinking, racing thoughts, flight of ideas, poor reality testing, agitation, and feelings of hopelessness and helplessness. It was reported that she took Zyprexa and Klonopin. Health care provider stated that she was free of suicidal ideation or psychosis and was able to care for self. They stated that she no longer required 24-hour hospital treatment then, and they recommended a less restrictive level of care. She improved and was discharged.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate. They also report that patients with aggression, homicidal or suicidal intent, plan, or behavior, manic episodes, psychotic symptoms, or severe agitation are candidates for inpatient hospitalization. In this case, this patient had initially presented with manic and psychotic symptoms, but during hospitalization there were no further reports of manic episodes or psychotic symptoms. Further documentation reports that the patient was stable over the past week, and she did not have a labile mood, aggression, suicidal or homicidal ideation, or hallucinations. It was noted that her speech was linear and not pressured. There were no reports of manic episodes, aggression, disruptive behavior, paranoid delusions, hallucinations, disorganized speech or thought process, homicidal ideation, plan, or intent, or severe agitation, acute medical instability or severe withdrawal requiring hospital treatment. The patient had no further severe psychiatric symptoms reported. Additionally, there were no reports of specific identifiable or quantifiable treatment objectives that could only be achieved in a 24-hour acute inpatient hospital setting or achieved in a less restrictive level of care. 

Based on the above, the medical necessity for the continued inpatient hospital stay is not substantiated.  The insurer's denial is upheld.
Diagnosis: Major Depressive Disorders
 
Treatment: Continued Inpatient Hospital Admission

The insurer denied the Continued Inpatient Hospital Admission. The denial was upheld.      

This is a middle age female who was admitted to an inpatient psychiatric hospital due to depressive symptoms that include depressed mood, suicidal ideation of not wanting to live but had no plan or intent. She also expressed feelings of worthlessness and isolation.  She had past history of Major Depression Disorder, seizures, cerebral palsy, and overactive bladder. She reports no previous psychiatric hospitalizations or treatments. The patient was treated with Lexapro, Abilify, Trazodone, Haldol, and Ativan. She was isolative but did participate in art group. While hospitalized, she remained depressed and suicidal. She was discharged after a period of stability.

Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders report that the least restrictive level of care for safe and effective treatment is appropriate and that patients with suicidal plan or intent or behaviors, or inability to adequately care for basic needs are candidates for hospitalization. She reportedly had suicidal ideation with depressed mood and feelings of worthlessness and was approved for hospital treatment. There were no reports of suicidal plan, intent, or behavior, self-injurious behavior, inability to adequately care for basic needs, psychotic or manic symptoms, aggressive, severely agitated, or threatening behavior, acute medical issues, or substance use issues as she denied substance use. She had no past suicide attempts, and no past psychiatric hospitalizations. She reportedly was living in a shelter but the chart notes that there was not specific evidence that she was an imminent danger to self or others or unable to adequately care for her basic needs. Also, as of then, there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24 hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting.

The carrier's denial of coverage for the continued inpatient hospital admission is upheld. The medical necessity is not substantiated.
Overbite/Underbite
Dental/Orthodontic Procedure

The patient is a old female with a Class I, crowded occlusion and a deep bite causing soft tissue damage on her palate. She is treatment planned for 18-24 months of orthodontics to correct her malocclusion which was denied based on lack of medical necessity.
The subject under review is the medical necessity of treatment with braces for this patient.

The health plan's determination is overturned.

The requested treatment of braces is medically necessary for this patient.
The patient's orthodontist has documented that the patient is damaging the soft tissue of her palate due to her deep overbite, and her cephalometric radiograph confirms this. Palatal tissue damage is a known side effect of deep bite malocclusions.(1)

A deep bite on its own is not a reason to treat with orthodontics. However, the patient is already damaging the soft tissue of her palate. Studies show deep anterior overbite is associated with periodontal attachment loss.(1) If left untreated this will compromise the bony attachment of the maxillary anterior teeth. This will worsen with time if left untreated and can lead to periodontal problems in the future that will be more invasive to correct than the orthodontic problem she currently has.
Decay, Root Involvement
Dental /Orthodontic Procedure 

The patient who presented to the dental office of the  provider for the evaluation and treatment of teeth #5 and 29. Provided for review are a narrative from the dental provider explaining radiographic opening under current restoration for #5 and 29 along with recurrent decay, full mouth radiographic images from 05/02/18, bite-wing images from 07/09/19, panoramic radiographs from 05/02/18, and American Dental Association (ADA) Dental Claim Forms.
In question is the medical necessity of the planned treatment of (2751) porcelain crown and (2954) prefabricated post and core for teeth #5 and 29.
The health plans determination of medical necessity is upheld in whole .
Based on the provided documentation there is no evidence of decay radiographically nor clinically to support the need for the requested treatment of (2751) porcelain crown and (2954) pre-fabricated post and core for teeth #5 and 29.The current documentation does not support the presence of decay at the margins of #5 and 29 neither clinically nor radiographically, hence removing any rationale for the replacement of the current crowns on those teeth. Because there is not a medical necessity need for the porcelain crowns, there is also not the need for post core and buildup for either teeth. Without evidence of decay radiographically or clinically to support the need for the planned treatment of porcelain crown and prefabricated post and core for teeth #5 and #29,  medical necessity cannot be established.
Diagnosis: Chest pain
Treatment: Inpatient admission
The proposed treatment, inpatient admission, was not medically necessary.

The patient is a woman who presented to the hospital complaining of chest pain for over one year. On examination vital signs were stable and chest pain was reproducible when palpating the sternum.  No other abnormal findings were noted. Past medical history was significant for diabetes mellitus.  Electrocardiogram revealed no evidence of ischemic changes and serial cardiac enzymes were within normal limits.  Computed tomography (CT) of the chest to rule out pulmonary embolism was normal.  The patient was ultimately discharged with outpatient follow up.

This patient presented with atypical chest pain that was present for one year's time.  Chest pain was reproducible when the sternum was palpated. Based on history and physical examination her pretest probability of coronary artery disease is low. (Reference 1)  Utilizing the HEART score she was considered low risk (three points). (Reference 2)  Utilizing the TIMI risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (Reference 3) 

Risk assessment of patients presenting with chest pain and no significant ST changes on electrocardiogram (ECG) was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction [MI], need for percutaneous coronary intervention [PCI], need for coronary artery bypass grafting [CABG], or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  Admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been treated at a lower level of care.
Diagnosis:  Psoriasis Vulgaris
Treatment:  Consentyx

The proposed Cosentyx is medically necessary.  

The patient is a male with psoriasis, treated with topicals, methotrexate, phototherapy, and Skyrizi.  The patient has cleared on Cosentyx samples.

Cosentyx is an approved, appropriate and effective medication for psoriasis.  A number of biologic agents are available for the treatment of moderate-to-severe plaque psoriasis.  Currently, the selection of the first biologic and the choice of sequential biologics in the event of efficacy/tolerability concerns is made using a limited evidence base.  It is generally considered medically necessary to continue a patient on a therapy to which they have favorably responded. 

The patient has already tried methotrexate.  Cyclosporine is not used for plaque psoriasis.
Diagnosis:  Dental Disorder.
Treatment:  Dental Implant Tooth #19.

The insurer denied the Dental Implant for Tooth #19.  The determination is overturned.

The patient presented to the oral surgeon for dental implant placement at the site of missing tooth #19.  The implant was performed.  At issue is the medical necessity of the dental implant for tooth # 19.

It is reasonable to restore a patient's dentition to first molar occlusion, which this procedure did.  It is considered a fairly predicable surgery with a high success rates with a variety of implant systems and applications (89 to 98 percent).  Replacement of missing teeth with dental implants is common practice in dentistry.  Loss of teeth without replacement may have several adverse outcomes, including among others masticatory dysfunction, speech and articulation errors, and pain secondary to chronic mucosal irritation and ulceration.  Since there is no tooth posterior to tooth #19, there is only a removable option, which is a partial denture, which is considered less ideal because it is removable versus fixed (which an implant is) and also because it is more suited to replacement of multiple teeth versus just one.  Therefore, the dental implant for tooth number 19 is medically necessary.
Diagnosis: Atrial Fibrillation
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of hypertrophic cardiomyopathy and paroxysmal atrial fibrillation. He presented to the emergency department complaining of palpitations. He also reported having had a few days of chills, cough and myalgias. He denied chest pain or dyspnea. His blood pressure was 115/86 millimeters of mercury (mmHg) with a heart rate of 109 beats/minute. His room air oxygen saturation was 98%. He was afebrile. His physical exam was unremarkable. Testing was positive for Influenza A. His serum troponin level was mildly elevated. He was treated with Tamiflu and intravenous digoxin and admitted to the hospital due to concern for acute coronary syndrome (ACS) based on the elevated troponin level. He was seen by a cardiologist who opined that there was no evidence of acute coronary syndrome (ACS). The patient was discharged. The medical necessity of an inpatient admission is at issue.

The inpatient stay was not medically necessary.
This patient was hemodynamically stable, there was no evidence of acute ischemia, he was not in decompensated heart failure, and was not at high risk for thromboembolism. For patients presenting with acute atrial fibrillation (AF), the safety a lower level care or discharge to home with close follow-up has been well demonstrated. As stated by Lin et al, "There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter. Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, and low molecular weight heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization. Likewise, Conti et al, based on an observational study of 3475 patients concluded, "In patients with AF, beyond the standard approach, the novel organization with an additional intensive observation unit for early pharmacological interventions and an outpatient clinic for elective treatment and short-term follow-up significantly reduced admission irrespective of independent predictors of hospitalizations."
This patient's serum troponin level was mildly elevated. This is a common finding in patients presenting with supraventricular tachyarrhythmias, including atrial fibrillation, and is not necessarily indicative of coronary artery disease or acute coronary syndrome. In this case, per the cardiologist, there was no evidence of ACS and no treatment for ACS was instituted. Thus, the troponin elevation in this case did not warrant an inpatient level of care.
Diagnosis: Alzheimer's dementia
Treatment: Consumer directed personal assistance services 50 hours per week

Summary:
This is a female with a history of Alzheimer's dementia. Due to this condition, she requires assistance with the majority of her activities of daily living (ADLs). The currently approved plan of 35 CDPAS hours/week is not sufficient to meet the patient's needs. Specifically, documentation from the patient's physician indicates that the patient's functionality and clinical status have progressively declined and she currently requires assistance with all ADLs including eating, cooking, bathing, toileting and laundry/housekeeping. For these reasons, the CDPAS at 50 hours per week is deemed medically necessary.
Diagnosis: Chron's Disease. 
Treatment: Stelara (ustekinumab). 
The insurer denied the Stelara (ustekinumab). 
The denial is upheld. 

The patient is a female with ileocolonic Crohn's. She has failed treatment with 
sulfasalazine, 6-MP (mercaptopurine), Methotrexate, Remicade and Humira. Her MD is requesting treatment with Stelara. 

No, the treatment with Stelara (ustekinumab) is not medically necessary. 

The patient has Crohn's, and she has failed Remicade and Humira. Per plan guideline, in order for criteria for Stelara to be met, the patient must have tried and failed Entyvio. As Entyvio is safe and effective treatment in patients with Crohn's who have failed an anti-TNF (tumor necrosis factor), and as there is no consensus in the literature supporting that Stelara is more effective than Entyvio for the treatment of Crohn's, the proposed Stelara is not medically necessary over the plan-preferred Entyvio, and the health plan did act reasonably, with sound medical judgment and in the best interest of the patient by denying it.
Diagnosis:  Appendicitis.  
Treatment:  Inpatient hospital admission.

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

This is a patient who presented to the Emergency Department with complaints of abdominal pain.  The patient reported that he had constant and moderate abdominal pain with loose bowel movements in the morning.  The physical examination revealed right lower quadrant abdominal tenderness and suprapubic region tenderness to palpation with no rebound or guarding.  The white blood cell count was 15.5.  CT scan of the abdomen and pelvis revealed acute appendicitis.  The patient decided to undergo non-surgical management and was treated with intravenous (IV) fluids, IV antibiotics, and pain medications.  The patient was discharged with follow-up for appendectomy planning with the general surgeon.

The length of hospital stay for this patient is consistent with what is seen in most studies on patients with uncomplicated appendicitis treated non-operatively.  Intravenous (IV) antibiotics is generally recommended for 3 days, typically on an inpatient basis, then followed by 7 days of oral antibiotics on an outpatient basis if patient responds to IV antibiotics.  Discharge criteria for patients with uncomplicated appendicitis treated non-operatively is antibiotics, control of pain with oral analgesics, and resolution of fever.  This patient had fever up to 102.  Another criteria that has been looked at for discharge is that the patient tolerates their diet (3).   He was started on clear diet in the morning, and his diet was advanced that evening.  Discharge the following day is reasonable, as it allowed for 24 hours of being afebrile, insured that he tolerated diet, and also that his WBC was improving.

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

The carrier's denial of coverage for the inpatient hospital admission is overturned.  The medical necessity is substantiated.