Persius/imr-appeals huggingface dataset:
Diagnosis: Facial cellulitis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This is a patient with a past medical history significant for acne who presented to the emergency room with complaints of facial cellulitis, right jaw pain, and peri orbital inflammation. 

Vitals on presentation included: Temperature 37.1 Celsius, Blood Pressure 138/78, Pulse 84, Respiratory Rate 18, oxygen (O2) saturation 98% on Room Air. Laboratory results included the following: white blood cell (WBC) count 11.5, hemoglobin 13.4, hematocrit 1.8, creatinine 0.7, glucose 120, lactic acid 0.7.
 
Patient was admitted to hospital for a facial cellulitis and empirically started on antibiotics. Maxillofacial computed tomography (CT) scan showed left preseptal soft tissue edema consistent with cellulitis. No evidence of extension into the orbit. Xray panorex was grossly unremarkable. Infectious Diseases consulted and adjusted antibiotics accordingly. Patient improved clinically, remained afebrile and hemodynamically stable. She was discharged to continue oral antibiotics as an outpatient. 

According to documentation, patient presented with a localized left pre-septal cellulitis. Patient was otherwise afebrile and hemodynamically stable. Laboratory results were unremarkable including a normal WBC. Patient had a localized infection, and no surgical intervention was required. Based on above findings, patient did not meet criteria for acute inpatient admission. Patient met criteria for observation level of management. 

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

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.
Diagnosis: Type 2 diabetes mellitus.
Treatment: Afrezza
The insurer denied Afrezza. 
The health plan's determination is overturned.

This is a male diagnosed with Type 2 diabetes mellitus with hyperglycemia. This request is for Afreeza. As reported, he has a severe phobia of needles making it so that he has been unable to give rapid-acting insulin injections. He has previously prescribed Novolog for treatment but failed due to his inability to inject due to his phobia.

The formulary alternative will be ineffective as the patient cannot self-inject insulin due to needle phobia.
Afrezza is FDA (Food and Drug Administration) approved for the treatment of diabetes. It has been shown to be beneficial in patients with diabetes. Studies have demonstrated the safety and efficacy of the medication and treatment of diabetes. There are no studies showing the superiority of Afrezza over injectable insulin. The patient is unable to self-inject to due needle phobia. A formulary exception is indicated.
Diagnosis: Type 2 Diabetes
Treatment: Freestyle Libre supplies
The insurer denied Freestyle Libre supplies.
The determination is upheld.

This is a male patient with type 2 diabetes with neuropathy treated with metformin and Ozempic. The patient's A1C is 5.8 percent (%). Freestyle Libre supplies were denied by the health plan and are under review for medical necessity.

The requested Freestyle Libre supplies are not medically necessary for this patient. The requested service is for the management of type 2 diabetes for a patient who is not on insulin therapy. Long-term continuous glucose monitoring has been shown to be safe and effective for people with type 2 diabetes on multiple daily insulin injections and basal insulin therapy. The safety and efficacy of continuous glucose monitoring has not been sufficiently studied in people with type 2 diabetes in the absence of insulin therapy to determine safety and efficacy in this clinical situation. The use of continuous glucose monitoring in this clinical situation is not supported by the Endocrine Society guidelines [1] or the American Diabetes Association clinical guidelines [2]. Therefore, the requested Freestyle Libre supplies are not medically necessary for this patient.
Diagnosis: Osteomyelitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 

Asked to review the case of an adult male that presented to the hospital with fever of 101.7 degrees F and symptoms of nausea and vomiting. Past medical history was significant for metastatic pancreatic cancer on chemotherapy, diabetes mellitus, hypertension, coronary artery disease status post right coronary artery (RCA) stent, and pulmonary embolus.  On arrival to the hospital blood pressure was 98/51 and pulse was 78. Physical examination was significant for poor distal pulses on lower extremities and  a second right toe amputation. Electrocardiogram demonstrated sinus rhythm with Q waves inferiorly and nonspecific T wave changes.  Serum blood testing demonstrated several abnormalities: White blood cells (WBC) 18,000 with bandemia, lactate of 2.0, troponin of 240, and B type natriuretic peptide of 3498.  Chest X ray revealed a right lower lung infiltrate. The patient was treated with intravenous antibiotics and admitted to the hospital for ischemia work up and sepsis work up.  Echocardiogram revealed an left ventricular ejection fraction (LVEF) of 55% with mild inferior 
wall hypokinesis and with moderate mitral regurgitation.  The patient was treated medically 
for type II myocardial infarction.  He was ultimately diagnosed with infection due to 
osteomyelitis of the distal extremity and was discharged on antibiotic therapy.

This patient presented with fever, nausea and vomiting and an elevated serum troponin level.  His pretest probability of coronary artery disease was high.(Reference 1)  Utilizing the HEART score (History, Electrocardiogram (EKG), Age, Risk Factors, and Troponin) he was considered intermediate risk. (Reference 2) Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have an intermediate 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. These findings are concerning and warrant management and evaluation at a higher level of care. Serial troponin measurement, echocardiography and ischemia work up were warranted prior to discharge. In addition to the issue of an acute coronary syndrome, this patient had multiple medical problems including metastatic pancreatic cancer and possible sepsis.  The patient was ultimately diagnosed with osteomyelitis that likely contributed to a type 2 myocardial infarction. (Reference 4).

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for full hospital admission is substantiated.
Diagnosis:  Dental Issues.
Treatment:  Braces and Monthly Visits.

The insurer denied the braces and monthly visits.  The health plan's determination is upheld.

The patient is a male with a Class I malocclusion, moderate maxillary crowding and moderate mandibular crowding, moderate overjet and moderate overbite. The subject to be determined is if the requested health service/treatment of braces and monthly visits are medically necessary.

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient.

The treatment for braces and monthly visits is not medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 19 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, deep impinging overbite with severe soft tissue damage, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeter (mm) or greater and underbite 3.5 millimeter (mm) or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, the requested health service/treatment for braces are not medically necessary.

The health plan's determination is upheld in whole.
Diagnosis: Cervicalgia, insomnia, low back pain, fibromyalgia, major depressive disorder
Treatment: Consumer Directed Personal Aide Services (CDPAS) for A total of 168 hours/week
The insurer denied the CDPAS for a total of 168 hours/week.
The denial is overturned.

This elderly female has medical conditions that include cervicalgia, insomnia, low back pain, fibromyalgia, major depressive disorder, anxiety, osteoarthritis, diabetes, hypothyroidism, anemia, abnormal gait, and urinary incontinence. Denial of Consumer Directed Personal Aide Services (CDPAS) for a total of 168 hours/week is being appealed. The health plan approved 70 hours/week. The patient needs assistance with ADLs (activities of daily living). She is frequently incontinent and cannot change or dress independently. A statement from her provider notes her condition is worsening. She has a history of multiple falls. She is unable to use her left arm after a shoulder injury. She uses the commode every 2-4 hours and cannot transfer without assistance. She needs to be cleaned and changed frequently during night due to incontinence. A statement from her children notes she lives alone. She has difficulty walking and cannot get to the bathroom or out of chair or bed when her aide leaves. She wakes up 5-6 times per night and needs assistance with going to the bathroom. 

The proposed treatment is medically necessary. 

Personal care service (PCS) is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift PCS is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This patient has multiple chronic conditions. Denial of CDPAS for a total of 168 hours/week is being appealed. The health plan approved 70 hours/week. The statement provided indicates that the patient's condition is deteriorating. She needs assistance with ADLs. She has urinary incontinence and requires assistance with transferring and toileting every 2-4 hours. The information provided supports that the patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved CDPAS for 70 hours/week is insufficient to support her continuous needs. The proposed CDPAS for a total of 168 hours/week, split shift is medically necessary.
Diagnosis: Shock from ICD (implantable cardiac defibrillator); lightheadedness
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult male that presented to the hospital following three shocks from his implantable cardiac defibrillator. Accompanying symptoms included lightheadedness and dyspnea. The patient's past medical history was notable for "septal defect repair", mechanical aortic valve replacement (AVR), stoke, myocardial infarction status post revascularization and heart failure with a reduced left ventricular ejection fraction of 15% (percent). The patient also has a subcutaneous defibrillator that was implanted for primary prevention several months prior to presentation. On arrival to the hospital, the patient's vital signs were stable (blood pressure 130/91 millimeters of mercury [mmHg', pulse 85 beats per minute). Physical examination revealed clear lungs and mechanical heart valve sounds at the aortic position. A 12-lead electrocardiogram revealed normal sinus rhythm without ischemic changes. Serum blood testing revealed a potassium of 5.9 and an international normalized ratio (INR) that peaked at 4.69. Implantable cardioverter defibrillator interrogation revealed a single shock for supraventricular tachycardia and the patient was admitted to the telemetry ward for observation and treatment. The patient ultimately underwent diagnostic electrophysiologic testing and no ablation was performed. The patient was discharged on escalating doses of beta blocker therapy.

The proposed treatment was medically necessary.

This patient presented with an implantable cardioverter defibrillator shock as a result of a rapid heart rhythm. The patient has an extensive cardiac history including mechanical aortic valve replacement, myocardial infarction, stroke and heart failure with a severely reduced ejection fraction of 15%. Hospitalization for diagnostic testing and treatment is clearly needed given the increased morbidity and mortality associated with both supraventricular and ventricular arrhythmias in this patient population. (Reference 1, 2) 
This patient required additional work up to assess the nature of his arrhythmia and potentially eliminate recurrent arrhythmia that might result in additional future implantable cardioverter defibrillator therapies. The patent appropriately underwent diagnostic electrophysiologic testing and was ultimately treated with escalating doses of beta blocker therapy. This patient's comorbid conditions and presentation required a higher level of care. In conclusion, inpatient hospital admission was medically necessary.
Diagnosis: Pressure ulcers

Treatment: Topical Oxygen Wound Therapy (TOWT)

The insurer denied coverage for Topical Oxygen Wound Therapy (TOWT)

The denial is upheld

 
According to the surgeon's note : "This patient has a past medical history that is significant for Orthostatic hypertension, reflex disease, chronic obstructive pulmonary disease (COPD), respiratory failure, muscle weakness, generalized edema, history of ventilatory dependence, Failure to thrive, contractions of the hip, mass of the duodenum, cognitive dysfunction who has deteriorated over the past seven months. Patient has dementia which has progressed. Approximately several months ago he was walking but he lost the ability to walk. He was taken to ... hospital. He was noted to have some sort of liver failure/cholecystitis with elevated bilirubin and they placed a t-tube since he was not an operative candidate. He came back home and became fluid over-loaded and he was noted to have edema in his legs as well as lungs. He was then taken back to the hospital and was intubated and then this led to a tracheostomy. He was in the hospital as well as a care facility and developed multiple pressure ulcers."  The surgeon's note indicates that the patient continues to have inadequate nutrition and is not being turned and off-loaded adequately.  Multiple studies have been published showing efficacy for Topical Oxygen Wound Therapy (TOWT) for the management of diabetic ulcers.  There are no published well-designed studies that show TOWT is effective in healing pressures ulcers in patients with poor nutrition, dementia, and respiratory failure.  The patient's ulcers were unlikely to heal regardless of the treatment provided due to his poor overall condition, and peer reviewed evidence that TOWT is superior to standard dressings in this clinical setting is not available.

Topical Oxygen Wound Therapy (TOWT) is not considered medically necessary for this patient. There are no published well-designed studies that show TOWT is effective in healing pressures ulcers in patients with poor nutrition, dementia, and respiratory failure.  The patient's ulcers were unlikely to heal regardless of the treatment provided due to his poor overall condition, and peer reviewed evidence that TOWT is superior to standard dressings in this clinical setting is not available.

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 Topical Oxygen Wound Therapy (TOWT) is not substantiated.
Diagnosis: Type 2 Diabetes Mellitus
Treatment: Formulary exception for Mounjaro 2.5 mg (milligrams)/0.5 ml (milliliters) Pen
The insurer denied the formulary exception for Mounjaro 2.5 mg/0.5 ml pen.
The denial is upheld.

The patient is an adult male with type 2 diabetes. The request for Mounjaro is under review. The prior request was denied coverage by the health plan, as the patient has not tried and failed or had intolerance or contraindication to three of the following: Ozempic, Rybelsus, Trulicity, and Victoza. This denial is being appealed. The patient has tried Ozempic, which caused nausea. The patient is being treated with metformin. The patient's A1C (glycated hemoglobin) is 6.0% (percent).

The health plan should not cover the formulary exception for Mounjaro.

This request is for Mounjaro for the treatment of type 2 diabetes. The health plan's formulary alternatives include Ozempic, Rybelsus, Trulicity, and Victoza. The patient has tried and was intolerant to Ozempic due to nausea. The documentation does not indicate that the patient has tried and failed the remaining alternatives or that the patient has a contraindication to these alternatives. The patient's A1C was 6.0%. He is being treated with metformin. The patient does not have a prior documented A1C that was elevated to document a need for additional glucose lowering medication. The American Diabetes Association clinical guidelines do not support the use of Mounjaro in this clinical situation. Mounjaro has risks, including nausea and vomiting. Therefore, no, the health plan should not cover the formulary exception for Mounjaro.
Diagnosis: Heart Failure
Treatment: Entresto
The insurer denied Entresto.
The determination is overturned.

This is a male patient with a history of atrial fibrillation and nonischemic cardiomyopathy. An echocardiogram showed a dilated left ventricle with global hypokinesis and a left ventricular ejection fraction of 25-30 percent (%). There was severe mitral regurgitation. Per the physician's appeal letter the patient has New York Heart Association Functional Class II heart failure. The medical necessity for Entresto is at issue.

Based on the information provided, Entresto is medically necessary.

Entresto (sacubitril/valsartan) is a relatively new, first-in-class medication that combines an angiotensin receptor blocker with a neprilysin inhibitor. In the pivotal trial of Entresto, 4187 patients with New York Heart Association (NYHA) Class II-IV heart failure and reduced left ventricular ejection fractions (less than or equal to 40%) were randomly assigned to receive either Entresto or standard therapy with enalapril, an angiotensin converting enzyme (ACE) inhibitor. During a median follow-up time of 27 months, the combined endpoint of death from cardiovascular cause or heart failure hospitalization occurred in 21.8% of the Entresto group versus 26.5% of the enalapril group; this difference was highly significant and in favor of the Entresto group. The American College of Cardiology (ACC) / American Heart Association (AHA) / Heart Failure Society of America (HFSA) guidelines for heart failure have given its use a Class I recommendation in this patient population.

Per the policy provided Entresto is medically necessary when:
1.	The individual is at least 18 years of age; (MET)
2.	The individual is using the drug for NYHA class II, III or IV symptoms: (MET)
3.	AND
4.	The individual has a left ventricular ejection fraction of 57% or less. (MET)
Diagnosis: Knee pain.
Treatment: Inpatient admission.
The health plan denied inpatient admission. 
The denial is overturned.

The patient is an adult male with knee pain. He has a history of severe morbid obesity, hypertension, and non-ischemic cardiomyopathy. He had undergone a left total knee replacement last year complicated by pain and decreased motion. He had undergone MUA (manipulation under anesthesia) x 2.

The patient was admitted to the hospital and discharged two days later. His surgery was arthrotomy, synovectomy and arthrolysis. He required PCA (patient-controlled analgesia), CVAC (Central Venous Access Catheter) and monitoring after the procedure.

The records show a complex and unique clinical condition to warrant the services provided. The important findings to substantiate inpatient admission are as follows:
BMI (body mass index) 45. This is an outlier to ambulatory arthroplasty. The patient would be at extremely high risk for complications.
The anesthesia time was nearly 5 hours. The patient has COPD (chronic obstructive pulmonary disease) with reported need for CPAP (continuous positive airway pressure). There would be an increased risk of pulmonary problems.
The patient had a drain in place with continued output. A special VAC (vacuum-assisted closure) drain was placed. It was not removed until POD (post-operative day) #2. A patient would not be able to be discharged with active drainage.
The patient was also found to have continued pain to require PCA (patient-controlled analgesia).

Based upon the described clinical condition, the inpatient admission and length of stay was warranted and medically necessary.
Diagnosis: Memory issues.
Treatment: personal care aide level 2- 84 hours/week, 12 hours x 7 days.
The insurer denied personal care aide level 2- 84 hours/week, 12 hours x 7 days.
The determination is upheld.


This is a female patient with a medical history notable for memory loss. The patient is approved for 3.5 hours 4 days per week and 3.25 hours 1 day per week (17.25 hours per week) of level 2 personal care aide services. The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and this request was denied by the health plan.
There were no letters of support or physician notes provided as part of this review. A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person. The patient was alert and oriented times three with periods of forgetfulness. She was self-directing and able to make her needs known. For her instrumental activities of daily living (IADLs), she requires maximal assistance for meal preparation and housework. She requires extensive assistance for finances, medications, stairs, shopping, and transportation. For her activities of daily living (ADLs), she requires extensive assistance for bathing. She requires limited assistance for dressing and toilet use. Other ADLs are independent. She is infrequently incontinent of urine. A task tool associated with the assessment recommended 15.76 hours per week to address her personal care needs. Compared to a prior assessment, she showed a modest decline in her functional status. At issue is the medical necessity of personal care aide level 2- 84 hours/week, 12 hours x 7 days.

The requested health service/treatment of personal care aide level 2- 84 hours/week, 12 hours x 7 days has not been demonstrated to be medically necessary for this patient.
The patient's UAS demonstrates that she needs assistance primarily with her IADLs but also with bathing. The task tool recommended 15.76 hours per week to address her needs, and she is currently approved for 17.25 hours per week. There was no evidence provided that the patient has any unmet personal care needs at her current level of service. There is, therefore, insufficient evidence for medical necessity for the requested increase.