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

Diagnosis: Acute Renal Failure.

Treatment: Continued stay at a skilled nursing facility (SNF).

The insurer denied coverage for a continued stay at a skilled nursing facility (SNF).

The denial is modified.

The patient is an adult with the following diagnoses: hypertension, schizoaffective disorder, gastroesophageal reflux disease (GERD) with a hiatal hernia, bipolar disorder, obesity, and paranoid schizophrenia. The patient also has a history of falls.  The patient was living in supervised housing before admission to an acute care setting due to acute renal failure.  Following discharge from the hospital, the patient was admitted to a post-acute skilled care setting.  The patient required maximal assistance and training to return the patient to the independence they had before their hospitalization. The medical record indicates that the patient made remarkable progress with skilled interventions. Within several weeks, the patient was managing with a rolling walker with limited assistance and required minimal assistance for dressing and personal hygiene. The patient still required partial assistance for standing.  The record states the patient also needed skilled training for negotiating stairs, as their apartment required managing six steps.  The patient was more independent in activities of daily living (ADLs) but the notes reflect that a barrier to discharge existed.  These are related primarily to finding a home health agency for home health aides to prevent deterioration of the gains made and falls. It appears that discharge was delayed for these reasons and for securing an outpatient mental health provider. The patient could have been discharged and received non-skilled care in a less intense setting.  Although there were barriers to discharge, skilled care in a skilled nursing facility did not appear to be needed.

Based on the above, the insurer's denial must be modified. 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 the continued stay at a skilled nursing facility (SNF) is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parosteal osteosarcoma
Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is overturned in part.

This is a patient with a history of a left femur parosteal osteosarcoma who previously underwent prior wide resection of this tumor and distal femoral replacement. The patient developed painful patello-femoral arthritis that required patello-femoral arthroplasty and revision of some of the distal femoral replacement components. The surgery was successful and there were no documented complications from the surgery or the hospital stay. The patient was admitted after surgery and was subsequently discharged home. At issue in this case is the medical necessity of the inpatient hospital stay.
The inpatient hospital stay was medically necessary in part for the patient to receive postoperative antibiotics and pain medication. The records also document that a drain was in place and its output was sufficiently diminished to allow removal. Lastly, the patient did require post-operative physical therapy following the operation. Appropriate progress with post-operative physical therapy was documented to safely allow discharge of this patient to home. At that time, further inpatient stay was not medically necessary for this patient. The rationale for this determination is based upon the provided medical records. The progress note for this patient documented that the patient had her pain well controlled and she participated in supervised physical therapy. The note also documented the the patient was voiding freely and tolerating a regular diet. In addition, the drain output was documented as only 5/10 cubic centimeter (ccs) in the past 24 hours. Physical therapy documented that the patient ascended 10 stairs, performed a safe bathroom transfer, and was able to complete gait training with axillary crutches and no pain. Based upon this documentation, the patient was stable for discharge to home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Detoxification 
 
Treatment: Inpatient Admission

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

This is a female patient admitted to inpatient substance detoxification treatment in early 2019 for detoxification from heroin and alcohol.  She reportedly had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 16 and Clinical Opiate Withdrawal Scale (COWS) of 17 and had withdrawal symptoms including tremors, sweats, nausea, vomiting, joint pain, yawning, sleeping problems, diarrhea, irritable mood, and anxiety.  She had past inpatient substance detoxification and rehabilitation treatments.  She reportedly had a past psychiatric hospitalization for bipolar disorder.  She was started on Methadone and Librium for detoxification.  She completed detoxification several days after her admission and was then converted to rehabilitation status.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  It also states that patients with significant alcohol use including large quantities and long durations of use are at higher risk for delirium tremens which is considered a life threatening condition.  It is reported that delirium tremens can occur within 3-4 days after stopping alcohol use.  This patient was having withdrawal symptoms on admission and continued to have reports of withdrawal symptoms throughout the first several days of admission and continued with two detoxification medications and had the detoxification treatment reportedly completed.  She took detoxification medication to modify withdrawal including Librium and Methadone and detoxification was reportedly completed within the fifth day of her admission.  She was at risk for complicated and life threatening withdrawal symptoms 3-4 days after admission and considered a risk and in need of at least 96 hours or 4 days of treatment in this inpatient hospital as a result.  

The carrier's denial of certain days of coverage for the inpatient hospital services is modified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe autism
Treatment: CDPAS 92 hours/week 
The insurer denied the CDPAS 92 hours/week.
The denial is overturned, in part. 

Yes, in part; CDPAS 56 hours weekly is medically necessary; however, CDPAS 92 hours/week is not medically necessary for this patient.

The patient is a male child with medical history significant for autism. He is essentially non-verbal with occasional vocalizations. He reportedly has self-injurious behaviors and is difficult to redirect or soothe. He requires constant supervision to prevent injury to self and damage to surroundings. He takes a high-calorie gluten-free diet by mouth. He is independent with transfers and mobility, but dependent for all activities of daily living. He can urinate independently but is incontinent of stool. He lives with his parents and three older siblings, two of whom attend school outside of the home and one of whom is home-schooled. His father works full-time outside of the home. The patient is no longer in school because his parents have declined to vaccinate, and vaccination is required for school attendance. 

The patient's parents currently receive six hours weekly of respite as well as 52 hours consumer directed personal assistance services (CDPAS). They are requesting an additional 40 hours weekly to cover the time that he would be in school. His calculated need has been determined to be 32 hours weekly. 

According to the American Academy of Pediatrics Guidelines for Home Care of Infants, Children, and Adolescents with Chronic Disease, "comprehensive planning should minimize physical and emotional risk to the patient, adverse effects on family members, or unforeseen financial burdens."  Further, "the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities." 

This male child has autism and requires constant supervision to maintain health and safety. He is not fully dependent in some activities such as eating and voiding but fully dependent upon caregivers for other activities such as bathing and stooling and dressing, some of which can be quite challenging. He is no longer in school because of the state vaccine regulations, increasing the number of hours that his family is responsible for his care. While there is no medical need to increase his CDPAS hours to the requested 92 hours weekly, the family has been basically just getting by providing for the needs of their son with the current 52 hours weekly. Based on his current needs, behavioral issues, and safety concerns, the most appropriate assistance would be 56 hours weekly (as an average of eight hours daily), to be apportioned by the family based on the participation of one or both parents. 

Therefore, an additional four hours is medically necessary for a total of 56 hours per week.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Flat Foot Deformity. 
Treatment: Procedure code 27899-RT-59 (unlisted procedure-right side-distinct procedure service) and 28899-RT-59 (unlisted procedure foot and toes-right side-distinct procedure service). 

The insurer denied coverage for procedure code 27899-RT-59 and 28899-RT-59. 

The denial is modified. 

The patient is a female with long history of being treated under the care of her physician. After failed conservative measures, the patient underwent flat foot reconstruction including both an Evans and a Cotton osteotomy. 

The literature has extensive evidence of the long-term positive outcomes in the use of these procedures for severe flat foot deformity. "The combination of these joint-preserving osteotomies with additional soft-tissue procedures allows realignment of the hindfoot with the goal of preventing further deformity or degenerative joint disease." (1) Patients tend to have high levels of satisfaction when it comes to correction of their flatfoot deformity with these types of osteotomies. Studies show a "high patient satisfaction based on the American Orthopedic Foot and Ankle Score (AOFAS) ankle-hindfoot scale and radiographic measurements demonstrate maintenance of correction of the adult acquired flatfoot." (2) When compared to a subtalar arthroereisis, a lateral column lengthening procedure results in no loss of correction and great results. (3) 

In the case of this denial, the fact remains that the procedures were the correct choice, however, it appears that the billing was done improperly and there are CPT (Current Procedural Terminology) codes that better encompass the procedures done, rather than the unlisted procedures that were billed. As such, there should be resubmission of the claim with the correct codes. 

The health plan acted reasonably in part. 

The insurer's denial of coverage for procedure code 27899-RT-59 and 28899-R  is modified. Medical Necessity is substantiated for the procedure that was performed; however, the coding must be corrected and resubmitted.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension (HTN), migraine headaches, seizures and hypothyroid.

Treatment PCW (personal care worker) service for 7 days per week, 24 hours per day, live in, 91 hour per week.

The insurer denied coverage for PCW service for 7 days per week, 24 hours per day, live in, 91 hour per week.

The denial is modified .

This is a patient with chronic medical problems including hypertension (HTN), migraine headaches, seizures and hypothyroid.  She currently has PCW services, 4.5 hours/day at 7 days/week.  She is requesting an increase of 24 hours/day at 7 days/week: totaling 91 hour per week.

According to the Uniform Assessment System (UAS) report, the patient requires maximal assistance for meal preparation, housework and shopping.  She requires limited assistance for personal hygiene, toilet use and walking.  Upper and lower body dressing requires extensive assistance.  She is continent of bowel and "occasionally incontinent" of bladder.  The patient's cognitive status is "minimally impaired."  The clinical records and assessments do not support the patient having functional and cognitive deficits to support the medical necessity of the requested personal care worker (PCW) services for 7 days per week, 24hours/day: totaling 91 hour per week.  However, an increase of PCW services 7 days/week for 8 hours/day will allow the patient to continue to safely live at home.    

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

From a physical medicine and rehabilitation perspective, an increase of PCW services 7 days/week, for 8 hours/day is clinically appropriate and medically necessary.  

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

The insurer's denial of coverage for personal care worker (PCW) service for 7 days per week, 24 hours per day, live in, 91 hour per week is modified. Medical Necessity is substantiated for an increase of PCW services to 8 hours/day, 7 days/week.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Gastritis/Duodenitis

Treatment: 30 feeding therapy visits

The insurer denied coverage for 30 feeding therapy visits.

The denial is modified.

The patient is a child born prematurely with a past medical history of chronic gastritis/duodenitis, food refusal, autistic spectrum disorder, global developmental delay, lactose intolerance, oral sensory issues and feeding difficulties requiring dependency on gastrostomy tube feeding. The patient is currently able to tolerate 50% (percent) of goal intake of Pediasure with the rest delivered via gravity feed via the gastrostomy tube (GT). The patient can self-feed high calorie liquids only but requires coaching/prompting. 

To address these needs, the patient was admitted to the feeding program virtually x (times) 30 visits. The patient's care was transitioned to twice weekly virtual sessions.

The patient showed progress with both the short and long-term goals established by the multidisciplinary feeding team with most goals attained by the discharge date. An additional 10 follow-up sessions were approved to ensure continued progress at home. 

Weight before, during and after the feeding therapies were documented as follows: 28.304 kilograms, 30.209 kilograms and 28.213 kilograms (home scale).

The insurer has denied coverage for additional 30 Feeding Therapy visits citing Centene Clinical Policy: Pediatric Oral Function Therapy CP.MP.188 criteria but approved 10 additional sessions.

The treating team is appealing for the full 30 visits.

The questions for review are the appropriateness of the denial and whether feeding therapy is medically necessary for this patient.

This patient's failure to thrive is certainly related to many of the above factors. It would be expected that with a structured feeding program, the patient would expand the variety of foods that they will accept and be able to take adequate intake to achieve a reduced dependence on GT feeds. In fact, the patient had progressed sufficiently during their time receiving therapy.

This child has documented weight loss since completing the more frequent feeding program visits (albeit on a different scale). This is somewhat surprising since the patient's total calorie intake should be achieved using their GT feeds to supplement any oral intake. The patient's diagnosis of autistic spectrum disorder and sensory/behavioral issues are playing a part in their marginal oral nutritional progress. The request for additional feeding therapy visits to reach the goals outlined by the feeding team is warranted and reasonable. However, starting with 20 additional feeding therapy visits is both medically necessary and in the best interest of the patient. 

Based on the above, the insurer's denial must be modified. 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 30 feeding therapy visits is not substantiated. However, 20 additional feeding therapy visits are both medically necessary and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic / Musculoskeletal
Inpatient Hospital

The patient is a male with a history of tobacco use, asthma, and hyperlipidemia. He presented to the emergency room with pain and swelling on the left side of the face, as well as chills and rhinitis. On exam, he was afebrile, and the vital signs were otherwise normal. He did not appear toxic. There was some left facial swelling. Labs were notable only for an elevated white blood cell (WBC) count of 16000. A computed tomography (CT) scan of the facial bones revealed soft tissue swelling over left maxilla consistent with an abscess and cellulitis, that was perhaps involving the maxillary alveolus. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with intravenous antibiotics and parenteral analgesics. The following day the ear, nose, and throat (ENT) consultant evaluated the patient and concluded that the patient did not have an ENT abscess and that the oral maxillofacial surgeon should be consulted. One day later the oral maxillofacial surgeon noted the report of improvement from the patient but concluded that there was possible osteomyelitis of the maxillary bone. Continuation of intravenous antibiotics along with surgical debridement was recommended. However, the patient did not want to remain in the hospital and was discharged on oral antibiotics, with a plan to see his dentist as an outpatient.

The health plan's determination is overturned in part.

Based on a review of the information provided, a one day acute care inpatient stay was medically necessary. The rationale for the inpatient stay was that the patient presented with objective evidence of a potentially life-threatening condition including facial erythema and tenderness, leukocytosis, and imaging consistent with maxillary osteomyelitis. The appropriate treatment, which would have been at the acute inpatient level of care, was intravenous antibiotics and urgent surgical debridement. However, there was a significant delay in service obtaining consultations that persisted to the point that the patient felt compelled to leave the hospital. Therefore, one day of acute inpatient care was medically necessary, but the second day was not.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Post-traumatic syrinx with spinal cord tethering
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned, in part.

The patient is a male who had an motor vehicle accident (MVA) causing multiple
fractures. The patient developed left leg weakness and foot drop and was found to
have post-traumatic syrinx with spinal cord tethering. The patient underwent T4-8 (fourth thoracic spine vertebra to eighth thoracic spine vertebra)
laminectomy, intradural exploration and detethering. The patient eventually
developed left foot weakness and magnetic resonance image (MRI) showed
myelomalacia and cord edema from C4 (fourth cervical spine vertebra) to the thoracic spine. The patient continued to have weakness and repeat magnetic resonance image (MRI) showed extension of syrinx to C2 (second cervical spine vertebra). The patient was recommended to have thoracic laminectomy and syringopleural shunt placement.

Yes, in part; the proposed inpatient admission was medically necessary for the first
five days of admission. However, the proposed inpatient admission was not
medically necessary for the last 10 days of admission.
The patient underwent a surgery that requires opening the covering of the spine.
There are many risks that can occur in the immediate postoperative period such as
hematoma, weakness, or cerebral spinal fluid (CSF) leak. The patient also required
intravenous (IV) pain medication, close neuromonitoring and weakness in the
proximal right leg requiring intravenous medications which ended. The patient
required acute inpatient hospitalization due to the nature of the surgery, the
immediate postoperative recovery period and the need for observation to avoid new
complications. The remainder of the dates do not demonstrate any findings that
warrant acute inpatient hospitalization.

The dates that do not show any need for acute inpatient stay should not be
approved because there were no treatments that required inpatient level of care.
However, the initial dates were medically necessary for the patient's immediate
postoperative recovery.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: ambulatory dysfunction
Treatment: home health care
The insurer denied Personal Care Services 24 Hours per Day, 7 Days per Week (Split-Shift).
The health plan's determination is overturned in part. Personal Care Services 24 hours per day (live-in), 7 days per week are medically necessary for the patient.

This is a case review for a female with medical history notable for incontinence, diabetes, and ambulatory dysfunction. 

The requested Personal Care Services: 24 Hours per Day, 7 Days per Week (Split-Shift) are not medically necessary for this patient.

Personal Care Services: 24 hours per day (live-in), 7 days per week are medically necessary for the patient.

The patient requires personal care assistance with all activities of daily living, including toileting, locomotion, transfers, and management of incontinence care. Her personal care needs can be expected to be continuous and unscheduled throughout the day and occasionally at night as well. She has no other informal support in place. Therefore, the patient requires 24-hour personal care assistance. A live-in personal care aide is medically necessary to address the patient's needs.

The documentation has not clearly demonstrated that split shift personal care services are medically necessary for the patient. There were no nighttime logs provided for review. The patient does not have any documentation of pressure ulcers which would require frequent turning and repositioning. A live-in personal care aide is required to receive at least 5 hours of uninterrupted rest at night. There is insufficient documentation to demonstrate that the patient's personal care needs would preclude a live-in aide from receiving adequate rest at night. Therefore, 24-Hour split shift services are not medically necessary for the patient. Personal Care Services: 24 hours per day (live-in), 7 days per week are medically necessary for the patient.