Persius/imr-appeals huggingface dataset:
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital stay. 

The insurer denied inpatient hospital stay.  The denial is overturned in part.

The patient is a male who was admitted with a history of perforated diverticulitis status post colectomy with colostomy (Hartmann's Procedure). He also had comorbid health conditions of diabetes, hypertension, coronary artery disease, and sleep apnea
The patient underwent evaluation with transthoracic echocardiogram that revealed an ejection fraction of 36%. Cardiology and pulmonary consultations were obtained. Gastroenterology consultation was also obtained. He also underwent bowel preparation for colonoscopy that was performed. Pulmonary function tests and a stress test was also performed. Computed tomography (CT) scan of the abdomen and pelvis was performed. The patient underwent surgical reversal of the colostomy and removal of a diaphragm pacing wire. The patient was clinically stable. He was started on a clear liquid diet. He was also receiving supplemental intravenous (IV) fluid. Pulmonary and cardiology notes document stability on the first post-surgical day. The patient complained of knee pain for which orthopedic and rheumatology evaluations were requested. The diet was progressively advanced, and the patient was discharged from the hospital.

The inpatient stay was medically necessary in part.

The records support that this patient was admitted to the hospital and underwent a presurgical evaluation, as is detailed above. This pre-surgical assessment lasted until the patient underwent surgery to reverse a colostomy. The records document post-surgical care that include a period of nothing by mouth (NPO) status, provision of IV fluid and analgesia. There was also progressive advancement of diet during the return of bowel function.

The records support that the pre-surgical assessment did not require an inpatient level of care. This care could have been rendered at a lower level of care status. Inpatient care was necessary and appropriate for the date of surgery forward. Surgical reversal of a colostomy does require provision of parenteral fluid and analgesia. It is appropriately anticipated that this care would extend over a period of greater than 2-days. 

The records support that inpatient admission was medically necessary in part and consistent with standards of care and the submitted Milliman Care Guidelines (MCG). This patient underwent surgery to reverse a colostomy. This operation requires a laparotomy and creation of a colonic anastomosis. His post-surgical course was complicated by a knee effusion that was assessed by the orthopedic and rheumatology services. 

His condition as documented in the medical records support the need for parenteral fluid and analgesia and was reasonably and appropriately expected to last more than 2 days.
Appeal type: Medical necessity
Decision: Overturned

Trauma/injuries:Other
Inpatient hospital

The patient is a male with a past medical history significant for cerebrovascular accident (CVA) with right-sided hemiplegia, hypertension, and benign prostatic hyperplasia (BPH) who presented to the hospital after he sustained a fall and stayed on the ground for an unknown duration. Because of expressive aphasia, the patient was unable to provide a detailed history. Based on the information obtained by the admitting physician, it looked like the patient stayed on the floor for a long time.

The health plan's determination is overturned in part. Care at the inpatient level of care was acceptable for 3 days for treatment of rhabdomyolysis and acute kidney insufficiency. This patient was admitted to the hospital after he sustained a fall and spent a long time laying on the ground. As a result of the fall, the patient developed rhabdomyolysis. His CPK level was abnormal at the time of admission. Rhabdomyolysis was affecting the patient's kidney function, and at the time of admission, the patient had some degree of kidney insufficiency and metabolic acidosis due to kidney insufficiency.the patient's rhabdomyolysis resolved and the patient did not require further administration of intravenous fluids.
At that time, it became clear that the patient's neurologic status was basically at the baseline, and the abnormalities on the neuro exam were chronic. The patient did not have any evidence of acute stroke.
At that time, he needed to be discharged to a rehabilitation facility, and social services were working on placement.
Appeal type: Medical necessity
Decision: Overturned

Cardiac
Inpatient hospital

Diagnosis: symptomatic sinus node disease
treatment: inpatients stay

The insurer denied the inpatient stay. The health plan's determination is overturned in part. A one-day stay was medically necessary. 

The patient is a woman with hypertension and atrial myxoma, status/post (s/p) excision, who presented to the emergency room (ER) with a one week history of headaches, mental fogginess, and lightheadedness. She had no chest pain, palpitations, nausea or vomiting. Her blood pressure was 143/65 mm Hg, pulse 37 beats per minute (bpm) and respirations 12. Pulse oximetry was 99% on room air.
She was admitted to the Intensive Care Unit (ICU), evaluated by Cardiology, and underwent placement of a dual chamber pacemaker for treatment of symptomatic sinus node disease. The procedure was uncomplicated, and she was discharged.

A one-day inpatient stay was medically necessary. The patient presented with hemodynamically unstable bradycardia, with heart rates in the 30's, associated with weakness, lightheadedness and headaches. An inpatient hospitalization and pacemaker implantation was indicated. The procedure could have been done the day after admission and the patient discharged as such. The pacemaker procedure and post-operative course were uncomplicated and discharge was appropriate at this point.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Right-sided neck pain and right arm pain.
Treatment:  Inpatient Hospital Admission.
The insurer denied Inpatient Hospital Admission.  The denial is partially overturned.

The patient is an adult female, who presented to the emergency department with right-sided neck pain and right arm pain. Magnetic resonance imaging (MRI) showed herniated disc, and the patient was recommended for surgery. The patient represented nearly 3 weeks later with the same complaints. The patient was admitted and underwent an anterior cervical discectomy and fusion (ACDF). The patient required intravenous Dilaudid on post-operative day # (number)  four times. X-ray was performed on post-operative day #2 and the patient was discharged on the same day.

The hospital treatment in the acute setting is approved as medically necessary for post-operative day #1 and day #2. However, the hospital treatment in the acute setting is not approved as medically necessary for the date of admission.

The records do not show any significant medical issues that required acute inpatient hospitalization on the date of admission. Based on the records, it is unclear as to why the patient was admitted, as she did not require acute inpatient level of care. 
However, the post-operative day #1 and day #2 are considered medically necessary, as the patient underwent surgery, and it is within the standard of care for close monitoring after the surgery. This is to evaluate for any neurological deficits or any issues, such as pain or weakness. Close monitoring is warranted in an acute level of care, as there are no other options at a lower level that are appropriate. In this setting, the 2 post-operative days are approved.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alzheimer's disease.
Treatment: Home care / personal care Home Health Care (HHC) - level 2 personal care services, per 15 minutes increase to 24 hours per day live in.
The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day live in.
The denial is modified.

This is a patient with multiple chronic medical problems including Alzheimer's disease. He lives alone. The patient is currently approved for at home care / personal care HHC - level 2 personal care services (PCS), per 15 minutes 49 hours/week.  

According to the Uniform Assessment System (UAS) report, the patient's cognitive status is "minimally impaired." However, he is "dependent in all decision making" and "unable to express his goal due to cognitive impairment." The patient requires maximal assistance for bathing, dressing, and toilet use. He is occasionally bowel and bladder incontinent. Extensive assistance is needed for personal hygiene, bed mobility and ambulation. His overall functional ability has declined since the prior assessment particularly for bathing, dressing, toilet transfer/use, bed mobility and ambulation. The combination of the patient's decreased cognitive status, medical condition and (declining) functional ability support the medical necessity of increasing level 2 personal care services, per 15 minutes from 49 hours per week to 84 hours per week. However, his condition and functional needs are not at a level or unpredictable as to require the requested 24 hours per day (live-in) PCA services. This physician would also agree the patient may require 24-hour monitoring. However, safety monitoring under PCS does not include monitoring an individual (e.g., with dementia) when no other Level I or Level II personal care services task is being provided.  

From a physical medicine and rehabilitation perspective, level 2 PCS, per 15 minutes increase to 24 hours per day live in is not medically necessary. However, increasing level 2 PCS, per 15 minutes to 84 hours/week is medically necessary.

The insurer's denial of coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day live in is modified. Medical Necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal. 
Skilled Nursing Facility. 

Diagnosis: Total Hip Arthroplasty. 
Treatment: Skilled Nursing Facility Stay. 
The insurer denied the continued Skilled Nursing Facility Stay. The health plan's determination is overturned in part. Five additional days are medically necessary. 

The patient is a female who underwent total hip arthroplasty and was admitted to a skilled nursing facility. 

Five additional days are medically necessary at the skilled cursing facility. 

The patient required moderate assistance (MODA) for bed mobility, MINA (minimum assist) for transfers and was ambulating 75' FWW (front-wheeled walker) contact guard assist (CGA). No stair training and occurred. The patient had progressed to MINA bed mobility, CGA transfers and was ambulating 100' FWW stand by assist (SBA). Stair training had not occurred. The patient was not ready for discharge at this point. Documentation noted the patient lived alone and had 2 steps to enter home and stair training had not been completed. Furthermore, she was continuing to make progress but was not yet at a safe level for discharge as she still required MINA for bed mobility and CGA for transfers. In addition, she was still requiring CGA for toileting and lower body dressing. 

The patient was SBA for bed mobility, SBA transfers, ambulating 150' FWW SBA, lower body dressing SBA and toileting SBA. The only concerning rehab factor was that she had completed 6 steps with MINA but as the documentation noted she only had 2 steps to enter her home. In addition, despite documentation stating she had 10 steps to her bedroom there was no mention that a bathroom was not on the first floor and it is acceptable to make a makeshift bedroom. 

Therefore, after day 5 the patient would have been safe to discharge to a lower level of care. It is noted that the patient was seen for leg edema and nasal congestion and Lasix 20mg three times per day (TID) x 3 days was ordered, but this does not support medical necessity as the patient had previously been treated for this same lower edema with the same order of Lasix 20mg x 3 days. In addition, while the patient complained of congestion, treatment was with over the counter medication of Flonase and Afrin. 

Therefore, from day 5 forward the patient was safe for discharge to a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth decay.
Treatment: D2752 White Glass With Gold Crown, Teeth 3,18,19.
The insurer denied the D2752 White Glass With Gold Crown, Teeth 3,18,19.
The denial is overturned, in part.

The patient is a male. The request is for dental benefits for White Glass with Gold Crown, teeth # 3,18,19. 

The health plan denied the claim because "teeth #3 and 18 did not exhibit significant decay or fracture to warrant a crown"; " tooth #19 had an inadequate root canal fill, and as a result crown placement would not be indicated at this time."

Yes, in part. The requested health service is medically necessary, in part.

Specifically, the requested White Glass with Gold Crown as it relates to teeth # 3 and 19 are medically necessary. The requested White Glass with Gold Crown as it relates to tooth # 18 is not medically necessary.
As supported by the x-ray images, tooth #3 has an existing large amalgam restoration encompassing more than 50% of the clinical crown. The placement of a crown is indicated to protect this tooth from fracturing due to the large existing restoration.

Tooth #19 has been endodontically treated (root canal); standard of care is for crown placement to restore function and prevent fracture post root canal.

Tooth #18 does not exhibit any decay, fracture or has been endodontically treated (root canal) and is not indicated for a crown.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, in part.
For Teeth #3 and 19; by not providing full coverage crown on these teeth, they will be more susceptible to significant fracture, which can lead to diminished function and eventual tooth loss.

For Tooth #18, since there was no pathology evident in the documentation submitted; not approving the crown was in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Mental Health
Mental Health: Inpatient

Diagnosis: schizoaffective disorder 
Treatment: Inpatient mental health
The insurer denied the inpatient mental health treatment. 
The health plan's determination is overturned in part. 5 additional days are medically necessary. 

The patient is a woman diagnosed with schizoaffective disorder, bipolar type (SCZBP). She also had a comorbid diagnosis of substance use disorder but details are not clear about the extent of her substance use or its relationship to her mental state in the emergency department. Case notes document that the patient suffers from chronic SCZBP. She was non adherent to her medications. She brought herself to the emergency department because of what her auditory hallucinations (AV) were telling her.

The Inpatient Mental Health Treatment (IMHT) for 5 additional days is medically necessary for several reasons. Her illness was severe and chronic. She was non adherent to taking her medications, meaning it would take some time to restore her to effective levels of medication. She was dilapidated with poor activities of daily living (ADL). She was at risk by not being able to care for herself. Case notes document that she was irritable and labile in her mood. While she showed some progress in being less paranoid, she had not reached a reasonable approximation of a baseline state. She had poor impulse control. Her speech was loud and pressured. She was uncooperative and irritable, angry and anxious. On day 3, she was less irritable, without agitation, but showing poor insight and judgment. She was not at a reasonable baseline state and was judged to be in continued need of IMHT. On day 4, she appears to have achieved maximum benefit and was at a baseline state. On that day, she had no deficits in impulse control. She had no suicidal or homicidal ideation. She was not experiencing any delusions or hallucinations. She was not agitated. She could therefore be discharged with good judgment, according to standards of best care, on day 5.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, hypertension, congestive heart failure and chronic obstructive pulmonary disease (COPD)

Treatment: Consumer Directed Personal Assistance Services (CDPAS) 40 hours per week

The insurer denied coverage for consumer directed personal assistance services (CDPAS) 40 hours per week

The denial is modified

The patient has chronic medical problems including diabetes, hypertension, congestive heart failure and chronic obstructive pulmonary disease (COPD). She lives with her son in a 2-bedroom apartment. She was approved for CDPAS 14 hours/week. Under review is the requested increase Consumer Directed Personal Assistance Services (CDPAS) 40 hours per week.

According to the Uniform Assessment System (UAS) report, the patient's cognitive skills are described as "modified independent." She is fully alert and oriented. She "can describe emergency event and able to dial 911 in emergency event." The patient requires extensive assistance for bathing and lower body dressing. Otherwise, personal hygiene, upper body dressing and toilet transfer/use requires only limited assistance. She is continent of bowel and bladder. She is able to walk with a cane and contact guard assistance. The clinical records do not substantiate a level of physical/cognitive impairment, debility or significant functional decline to warrant the medical necessity of an increase in CDPAP hours to 40 per week. However, increasing CDPAP to 28 hours/week is clinically appropriate; allowing the patient to continue living safely at home.  

The healthcare plan acted reasonably in part, with sound medical judgment and in the best interest of the patient. From a physical medicine and rehabilitation perspective, Consumer Directed Personal Assistance Services (CDPAS) 40 hours per week is not considered medically necessary. However, 28 hours per week is considered medically necessary.

The insurer's denial of coverage for consumer directed personal assistance services (CDPAS) 40 hours per week is modified. Medical Necessity for increasing CDPAP to 28 hours/week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

The patient has a past medical history significant for bipolar disease who presented with worsening frequency of rectal prolapse and incontinence. Of note, the patient was also facing eviction from her apartment due to cleanliness issues related to the incontinence. The prolapse was reducible but there was no surgeon at that hospital capable of addressing the rectal prolapse so she was transferred for higher level of care. Patient was evaluated by surgery who initially recommended outpatient surgical intervention. Patient then stated she was suicidal which required involvement of psychiatry who recommended inpatient hospitalization with 1:1 sitter due to harm to self and inability to care for herself in the community.

The health plan's determination is overturned in part. The inpatient stay was medically necessary until 1/25/19 (day of surgery) due to due to a psychiatry hold for potential to harm self with 1:1 sitter. The patient had complex social and mental health issues which required fixing the rectal prolapse prior to surgery as well as involvement of psychiatry and 1:1 sitter due to concern for harm to self.

However, from 1/25/19 forward, the patient's care could have been provided at a lower level of care (e.g. pain control, diet advancement after robotic rectopexy, as well as resolution of social issues so patient could be discharged back to home). After surgery, the patient's diet was advanced and her disposition was determined with the assistance of social work and psychiatry. This did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Cardiac/Heart Problem
Inpatient Hospital

The patient is a man with nonischemic cardiomyopathy, chronic systolic heart failure, with ejection fraction (EF) 30%, s/p implantable cardioverter defibrillator (ICD) placement, chronic kidney disease (stage 3), morbid obesity (body mass index (BMI) > 40), sleep apnea, not compliant with continuous positive airway pressure (CPAP), hypertension and asthma.
He presented with dyspnea and a cough productive of yellow/white sputum. He had recently been hospitalized with a congestive heart failure (CHF) exacerbation and was discharged the day prior to this admission. He was admitted for further evaluation and treatment. He was felt to have been prematurely discharged, and required additional diuresis. It was also noted that he needed help at home.

The health plan's determination is overturned in part. A 2 day inpatient stay was medically necessary. The patient was felt to have decompensated heart failure - he was dyspneic, tachypneic, and with signs of acute CHF - including pulmonary rales and moderate leg edema. These symptoms and signs did not resolve in the emergency room. Per Milliman Guidelines, inpatient admission is indicated for patients with heart failure who have tachypnea and dyspnea over baseline which persist despite emergency room treatment. He also had a cough, productive of yellow sputum, and this comorbid condition, along with heart failure, is another reason for admission. Per Milliman guidelines, the usual length of stay is 2 days. Hospitalization beyond this time frame is not supported by the medical records provided.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abfraction lesions
Treatment: Porcelain veneers over teeth numbers 6, 7, 8, 9, 10, and 11
The insurer denied coverage for porcelain veneers over teeth numbers 6, 7, 8, 9, 10, and 11
The denial is overturned in part.

Upon review of the submitted documentation including radiographs, panoramic x-rays, and intraoral clinical images, as well as the insurer correspondence, it appears that this patient presented for veneers on teeth # 6, 7, 8, 9, 10 and 11. The dentist identified abfraction lesions, enamel fractures on teeth # 8 and 9, incisal wear and sensitivity as reasons to justify the veneers. The insurer has denied coverage for orthodontic treatment as not medically necessary as they stated these teeth did not have extensive loss of tooth structure due to decay or fracture. The definition of abfraction lesions indicates that loss of tooth structure has occurred.

Due to the poor quality of the x-rays and intra-oral pictures received, only the medical/dental necessity of restorative treatment on teeth # 8 and 9 could be determined. 

The health plan acted reasonably in part.

Veneers for teeth # 8 and 9 is considered dentally necessary for the patient. The insurer's denial of coverage for veneers on teeth # 6, 7, 10 and 11 is upheld 

The insurer's denial of coverage for porcelain veneers over teeth numbers 6, 7, 8, 9, 10, and 11 is modified. Medical Necessity is substantiated for teeth # 8 and 9.