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

Diagnosis: Mental Health (Schizoaffective Disorder)
Treatment: Mental Health: Inpatient

Summary: This patient was admitted for inpatient psychiatric treatment due to psychotic symptoms including auditory and visual hallucinations derogatory in nature and reports that he was seeing shadows and visions, bizarre thoughts as he had a delusion that his body was shrinking, slowed thought process and thought blocking, disorganized thoughts, uncooperative behavior, urges to hurt self, poor activities of daily living (ADL's), impaired judgment and insight, poor impulse control, sad and irritable mood. He had a diagnosis of Schizoaffective Disorder with multiple past and recent psychiatric hospitalizations. He was living in a shelter and was unemployed. He refused medications at times including Haldol and was switched to Prolixin. He was discharged with follow-up referral for outpatient psychiatric treatment.

The insurer has denied coverage for the continued inpatient psychiatric hospital treatment as not medically necessary treatment. The denial was modified.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior, or inability to adequately care for basic needs are candidates for hospitalization. The denial was partially approved because the patient still had psychotic symptoms during the denial period including internal preoccupation, agitation, poor hygiene, impulse control, and insight. He was at risk of decompensation of psychotic symptoms, so he still needed 24 hour hospital treatment then. The subsequent days of the admission were denied because he did not have reports of significant psychotic symptoms requiring continued 24 hour hospital treatment. Notes reported he denied feelings of depression, suicidal ideation, auditory or visual hallucinations. Notes reported that he denied harmful thoughts to self or others and denied perceptual changes. Notes reported that he denied suicidal or homicidal ideation, hearing voice or seeing things not there though he reported hearing music, and it was reported that his thoughts were more logical, mood was calmer, and insight was improving. Notes reported that he had euthymic mood and no suicidal or homicidal ideation and he was discharged. There were no reports of significant psychotic symptoms, suicidal or homicidal ideation, aggressive, self-injurious, or severely agitated behavior, manic or major depressive episodes, acute medical instability, severe withdrawal symptoms, or inability to adequately care for his basic needs.  Also, 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 then.  Approval of 1/25/19. Denial of 1/26/19-1/29/19.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 Diabetes Mellitus, hypertension, memory loss, cervical/lumbar radiculopathy, osteoarthritis, urinary incontinence

Treatment: Increase in Personal Care Worker (PCW) services from 7 days per week, 7 hours per day, 49 hours per week to 12 hours per day, 84 hours per week.

The insurer denied coverage for an increase in Personal Care Worker (PCW) services from 7 days per week, 7 hours per day, 49 hours per week to 12 hours per day, 84 hours per week

The denial is modified

This patient is a female with multiple medical problems including diabetic neuropathy, atrial fibrillation and hypertension. The insurer approved a PCW increase from 7 hours/day (49 hours/week) to 8 hours/day (56 hours/week). Under review is the request for an increase in PCW services to 12 hours/day (84 hours/week). 
 
According to the Uniform Assessment System (UAS) report, the patient is modified independent with making decisions and has appropriate short-term memory that has not changed over the prior 90 days. She can direct her own care and activate a personal emergency response system in case of an emergency. However, her functional status has declined; particularly with activities of daily living (ADL). She requires extensive to maximal assistance for bathing personal hygiene and dressing. She requires limited assistance for toilet transfer and extensive assistance for toilet use. She is frequently incontinent of bladder and infrequently of bowel. She has vision and hearing deficits that also continue to decline. The PCW hours were increased to 7 days per week, 8 hours per day: 56 hours per week.  However, increasing PCW to 10 hours/day (70 hours/week) is a more reasonable clinical decision in order to allow Ms. Bortnovskaya to continue living safely at home.   
 
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 an increase in Personal Care Worker services from 7 days per week, 7 hours per day, 49 hours per week to 12 hours per day, 84 hours per week is modified. Medical Necessity is substantiated for 10hrs/day (70 hrs/week).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Knee Arthroplasty 
 
Treatment: Continued Inpatient Admission 

The insurer denied the continued inpatient admission. The denial was modified.  
This is a female patient with a medical history of diabetes mellitus, morbid obesity, status post gastric bypass over a decade ago, meningioma, status post craniotomy, gastroesophageal reflux disease (GERD), epilepsy, allergic rhinitis, adjustment disorder, and osteoarthritis. She was status post a left knee arthroplasty (TKA). She was transferred to a subacute rehabilitation facility for ongoing rehabilitation. The patient was appropriately admitted to a subacute rehabilitation facility after undergoing a left TKA. The therapy notes document the patient's functional improvement. This physician agrees that the patient continued to require a level of assistance (minimal to stand by) for functional mobility according to a physical therapy progress note 2 days after admission thereby supporting continued subacute rehabilitation. However, the patient required only supervision to modified independence for bed mobility, transfer activities and ambulating with a walker approximately 250 feet several days prior to discharge. A similar level of (supervised) modified independence for activities of daily living was documented in the occupational therapy notes at the same time. Subsequent care could have been safely provided at a lower level (e.g., long term care or home with visiting therapy services).  In addition, there were no complex nursing issues or acute medical problems that required skilled nursing or physician services. 

The healthcare plan did not act reasonably or with sound medical judgment or in the best interest of the patient in their denial of the continued inpatient admission for the first 10 days of her admission. They did act reasonably with sound medical judgment and in the best interest of the patient in their denial of the continued inpatient admission for the last several days of her admission. 

Based on the above, the insurer's denial is modified.  Approve the first 10 days and deny the last several days.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overdose
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is overturned in part.

This is a male patient with a past medical history (PMH) of alcohol abuse disorder who was admitted with complaints of (c/o) ingestion of about eight 150 milligram pills of trazodone and suicidal ideations. His vital signs were notable for systolic blood pressure (SBP) in the 80s, hypoxia with peripheral capillary oxygen saturation (SpO2) in the high 80s. Lab work was notable for an elevated anion gap, transaminitis. Imaging studies included a chest x-ray (CXR) which showed no focal infiltrates.  Poison control was called and advised to monitor for bradycardia, seizures, and electrocardiogram (EKG) changes, but noted that with the low amount of trazodone ingested that there was no significant concern for toxicity. The patient was diagnosed with suicidal ideations, intentional overdose, and alcohol withdrawal and treated with intravenous fluids (IVF), which improved his vital signs, 1:1 observation, Clinical Institute Withdrawal Assessment (CIWA) protocol, and expert consultations. The CIWA was noted to be 3 and the patient was recommended for inpatient psychiatry transfer, but no bed was available. At issue is the medical necessity of an inpatient level of care.

In part. This patient presented to the emergency department (ED) after an intentional overdose of trazodone and suicide attempt. Poison control was called and they recommended monitoring for bradycardia, seizures, and EKG changes, while the patient was found to have hypotension, hypoxia, and an elevated anion gap, increasing the patient's risk of clinical decompensation. In addition, the patient was a suicide risk and required 1:1 sitter observation to monitor the patient for further suicidal attempts, while the patient had concomitant alcohol withdrawal and was considered at high-risk of severe withdrawal symptoms, requiring CIWA protocol and close monitoring while on both trazodone and benzodiazepines (BZDs).
However, the patient was documented to have a low CIWA, there was minimal concern for continued trazodone toxicity, and the patient's vital signs normalized, at which point the patient could have been safely treated at a lower level of care, especially as it is documented that the patient's discharge was delayed due to the lack of an inpatient psychiatry bed rather than continued acute medical illness. Overall, this patient required close clinical monitoring after an intentional trazodone overdose, and initially, this could not have been safely provided at a lower level of care. However, care could have been provided at a lower level once the patient medically stabilized.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity, Mental Retardation, Autism, Metabolic Syndrome, and Pre-Diabetes
 
Treatment: 56 hours per week of Personal Care Assistance (PCA) Services 

The insurer denied the 56 hours per week of Personal Care Assistance Services. 
The denial was modified. 

This is a male patient whose diagnoses include pre-diabetes, hyperlipidemia, autistic range and mental retardation, obesity, metabolic syndrome. Information from an individualized education program (IEP) included a classification of autism. The patient received special education, and graduated from high school.  He had moderate cognitive deficits and profound deficits in receptive and expressive language skills, limited attention span, required positive reinforcement, and repetitions to complete every task. The patient exhibited echolalia; he flapped his hands throughout testing, and rocked back and forth. Responses were often delayed. Based on testing, cognitive functioning was noted as moderate intellectual disability.  The patient is pre-diabetic. He is followed by a primary care physician; however, he does not take any medications. There are some behavioral issues and he has difficulty communicating his needs; he is occasionally aggressive (pushing). The patient can perform activities of daily living (ADLs) but needs assistance. He can perform some simple household tasks with supervision. He travels in the community supervised at all times.  He needs verbal prompts to pay attention to his surroundings. He knows his address; has some reading/writing skills, but poor comprehension. 

The Uniform Assessment System -Aide Task Service Plan (UAS-ATSP) Summary of Hours Recommended allocates relatively short periods of time for assistance with ADLs (10 minutes for bathing, 5 minutes for each personal hygiene task).  On review of the reports from the psychologist and Licensed Clinical Social Worker (LCSW), it is noted that the patient needs frequent prompting to complete tasks and is slow or resistive to respond at times to perform various activities.  It was noted that the patient has a limited attention span and needs repetitions to complete tasks.  With these behavior patterns, it is reasonable to consider that the patient needs more than 5 or 10 minutes per task for bathing and personal hygiene to allow for cognitive and behavioral delays in completing the tasks.  For these ADLs, increasing the time allocated by 10-15 minutes per task is a reasonable accommodation for a patient with this type of behavioral history. 
With the addition of 5-15 minutes per task for bathing and personal hygiene, plus 10-15 minutes for upper and lower body dressing, plus 20-25 minutes per meal (x 2 meals/day), plus the time previously allocated to instrumental activities of daily living (IADLs) on the UAS-ATSP, 30 PCA hours per week can provide a reasonable timeframe to accommodate the patient's IADL and ADL needs.

The carrier's denial of coverage for 56 hours per week of personal care assistance services, from is modified.
Appeal type: Medical necessity
Decision: Overturned

This patient presented to the hospital with the complaint of severe abdominal pain and vomiting of 1-day duration. She had been having abdominal pain for several weeks.
The patient reported increasing abdominal pain and she presented to the emergency department (ED). Initial vital signs were normal. The abdomen was tender in the right upper quadrant. Lab data showed an elevated alkaline phosphatase of 168. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were elevated at 1330 and 751, respectively. Total bilirubin was 1.6. Electrolytes and renal function were normal. Abdominal ultrasound showed gallstones, biliary sludge.
The patient was admitted for provision of intravenous (IV) fluid, antibiotics, and antiemetics. Gastroenterology consultation was obtained. Magnetic resonance cholangiopancreatography (MRCP) showed small stones and sludge in the gallbladder and dilated common bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) was performed showing a common bile duct (CBD) stones. The duct was swept with a balloon and a sphincterotomy was performed.  The patient was provided a liquid diet; she was afebrile and was without abdominal pain. The patient underwent cholecystectomy. The post-surgical recovery was uncomplicated, and she was discharged home.

The health plan's determination is overturned, in part. 

Inpatient stay was medically necessary in part. The care and treatment provided required the coordinated care of the GI and surgical services, Imaging with MRCP, and treatment with ERCP in addition to provision of IV fluid, antibiotics, pain medications and parenteral antiemetic medications. The care and treatment provided for cholecystitis and CBD stones reasonably spanned a period of greater than 2-nights and was appropriately provided in the inpatient setting. However, cholecystectomy was delayed. Had surgery been performed following successful ERCP the day prior, then this patient would have been stable for discharge from the inpatient setting earlier. There was a delay in performance of cholecystectomy that resulted in a 2-day increase in the hospitalization.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Female infertility
Treatment: Formulary exception for Gonal-F Menopur, Ganirelix, HCG and Leuprolide

The health plan should cover the Formulary Exception for Gonal-F Menopur, Ganirelix, HCG and Leuprolide, in part.

Specifically, the health plan should cover the Formulary exception for Gonal-F, Menopur, HCG, and leuprolide, but not for ganirelix.

The patient is a female undergoing IVF (in vitro fertilization) for oocyte cryopreservation.

In review of the current literature, the use of GnRH (leuprolide) in the setting of IVF is well established for its use of controlled ovarian stimulation and triggering of ovulation.  The use of Gonal-F and Menopur are also well established as stimulants to follicular growth.  HCG is also a known and established ovulation trigger. Therefore these medications are medically necessary as supported by current medical literature, since they are accepted standards of medical practice.  

There is no evidence that Ganirelix, a GnRH antagonist, is needed over the GnRH agonist in the records provided.  Therefore, this is not medically necessary at this time.

The medications except for Ganirelix are well established in the literature as a protocol for in vitro fertilization.

The health plan's denial rationale indicates that they do "not allow coverage of Gonal-F, Menopur, Ganirelix, hCG and leuprolide acetate unless the patient is undergoing ovulation induction."  As this patient is undergoing IVF, the health plan should cover the Formulary exception for Gonal-F, Menopur, HCG, and leuprolide, but not for ganirelix.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mood Disorder 
Treatment: Inpatient Psychiatric Admission 

The insurer denied inpatient psychiatric admission. The denial was modified. 

This is a male patient was admitted to the hospital for inpatient mental health treatment due to severe behavioral symptoms. These behaviors included aggressiveness, poor impulse control, severe agitation, restlessness, extreme anger, and medication noncompliance. He reported that he lived with his parents and he smoked 6-8 joints of cannabis per day; he had positive toxicology for cannabis. He had a past psychiatric history of Mood Disorder with past hospitalizations. It was reported that he had taken Zoloft and Risperidone. He was discharged home after a period of medical stability. 

The MCG Behavioral Health Inpatient Level of Care Adult criteria report that in order to meet criteria for inpatient behavioral level of care, a patient needs to present as an imminent danger to self, imminent danger to others, have severe psychiatric or behavioral symptoms, have severely dysfunctional living including inability to care for self, have an unwillingness to participate voluntarily, or a less restrictive level of care is not feasible. InterQual  Behavioral Health Adult  Psychiatry inpatient medical necessity criteria reports that  criteria for inpatient treatment is met if one has any of the following: assaultive behavior within 24 hours, catatonia, command hallucinations to harm self or others, destruction of property with poor impulse control within 24 hours, disorganized behavior, unstable eating disorder, fire setting, homicidal or suicidal attempt within 24 hours, suicidal or homicidal ideation with high risk for an attempt, mania, risk of harm to self or others, non-suicidal self-injury and continued danger to self, positive psychotic symptoms with risk of harm to self or others, post-traumatic stress disorder (PTSD) with risk of harm to self or others, psychomotor agitation and potential for violence, severe social withdrawal and refusing treatment, unavailable support or inability to provide needed care and supervision and there is acute deterioration in functioning. This patient had severe psychiatric and behavioral symptoms requiring 24-hour hospital treatment including aggressive behavior and property destruction. 

As a result, modify the previous decision and approve coverage for inpatient mental health treatment in this hospital the initial day of admission, but deny coverage for inpatient mental health treatment in this hospital for the following two. The insurer acted reasonably and with sound medical judgment and in the best interests of the patient for the last two days of admission, but not on first one. 

The carrier's denial of coverage for the inpatient psychiatric admission from is modified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, Hypertension, Diabetes, Mellitus, Depression and Anxiety. 
Treatment: Increase Consumer Directed Personal Assistance (CDPAP) Services For The Total Amount of 49 Hours A Week. 

The insurer denied the Increase Consumer Directed Personal Assistance (CDPAP) Services For The Total Amount of 49 Hours A Week. 

The denial is partially overturned. 

The patient is a male with a history of Alzheimer's disease, Hypertension, Diabetes Mellitus, Depression and Anxiety. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review was requested for potential approval of 49 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support. 

Yes, in part. The requested 49 hours/week Personal Assistance Services is deemed medically necessary, in part. Specifically, 42 hours/week of personal assistance services are medically necessary.

The patient is a male with a history of Alzheimer's disease, Hypertension, Diabetes Mellitus, Depression and Anxiety. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities. An assessment of the patient's functionality and ability to perform ADLs (activities of daily living) was completed and revealed that 42 hours/week Personal Assistance Services is sufficient to meet the patient's current needs. 

Specifically, the assessment revealed that the patient has sustained no recent falls, had no recent ER (emergency room) visits or hospitalizations. Furthermore, the patient's abilities to perform physical functioning stayed the same for dressing upper and lower body, walking, bathing, transfer toilet, eating, meal preparation and ordinary housework compared to his abilities when assessment during the prior Health Assessment Report. 

There is no additional documentation which demonstrates that the patient has sustained further functional loss since the date of this last assessment. 

Given that the assessment revealed that the patient needs 42 hours per week, the health plan's approved plan of 35.5 hours/week is not sufficient to meet the patient's needs. Also, given the above, 49 hours/week is in excess of the patient's needs. Therefore, 42 hours/week of consumer directed personal assistance program services are medically necessary. 

As per above, 42 hours/week of consumer directed personal assistance program services are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic thrombocytopenic purpura.
Treatment: Inpatient admission.

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

This male patient has no significant past medical history.

Given the patient's three-day history of dizziness and severe thrombocytopenia (platelet count 12), hospitalization to monitor within a protective environment was within standard of care and supported by current guidelines, especially given the precipitous drop from a platelet count from 38 the day before. It was reasonable and within standard of care for the team to discharge the patient home with a platelet count of 20 after 1 day of hospitalization since the patient was asymptomatic and without evidence of bleeding. Continued hospitalization for further improvement of platelet count was no longer deemed necessary.

As such, hospitalization for monitoring and a protective environment was within standard of care and appropriate. However, after 1 day of observation and denial of any symptoms and follow-up platelet count of 20, it would have been reasonable and within guidelines to then discharge this patient for further ambulatory management. 

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

The carrier's denial of coverage for the inpatient admission is modified.  The medical necessity is not, in part, substantiated.