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

Dental issues
Dental/orthodontic

Diagnosis: Dental issues
Treatment: Surgical Extraction of Teeth 21 and 28 and Placement of Intra-Socket Dressing for Teeth 12, 21, 28 and 5
The insurer denied Surgical Extraction of Teeth 21 and 28 and Placement of Intra-Socket Dressing for Teeth 12, 21, 28 and 5
The health plan's determination is overturned in part. 

The patient is a young female with dental issues who has been denied Surgical Extraction of Teeth 21 and 28 and Placement of Intra-Socket Dressing for Teeth 12, 21, 28 and 5.

The Surgical Extraction of Teeth 21 and 28 is medically necessary for this patient. The patient is having braces and needs extractions. When there is inadequate space in the arch for all the teeth, extractions are needed to provide the available room to align the teeth. Orthodontic treatments commonly involve premolar extractions for providing space and are known as therapeutic extractions. Surgical Extraction of Teeth 21 and 28 is medically necessary.
The Placement of Intra-Socket Dressing for Teeth 12, 21, 28 and 5 is not medically necessary. A dressing in a socket is done to aid in hemostasis. There is no medical history and no justification from the provider that dressings are needed to provide additional hemostasis for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory Failure
Treatment: 168 hours per week, two thousand one hundred and eighty-four (2,184) units of private duty nursing (PDN, T1000) services

The insurer denied coverage for 168 hours per week, two thousand one hundred and eighty-four (2,184) units of private duty nursing (PDN, T1000) services.
The denial is modified.

This is a child with a history of Prader-Willi syndrome, global delay, respiratory arrest, respiratory failure, encephalopathy, prediabetes, polyphagia, mild pulmonary hypertension, right ventricular systolic dysfunction, obstructive sleep apnea and obesity. Per the detailed letter of medical necessity, the patient was hospitalized for respiratory failure, cardiac arrest and infection. A tracheostomy was placed. The patient is stable on humidified oxygen via trach collar, requires continuous oxygen monitoring, chest physiotherapy twice daily, deep tracheal suctioning 4-6 x (times) a day, oral suctioning as needed, nebulizer treatments, mildly thick liquids orally and regular solids with constant supervision. He is risk of respiratory arrest and death if his artificial airway has a mucous plug. He has developed airway obstruction multiple times throughout this hospitalization and requires someone awake and alert to intervene in an airway trach emergency.

The patient has been hospitalized for now resolved tracheitis. He is stable but unable to be discharged home without PDN in place. He requires continuous humidified supplemental oxygen overnight, nebulizer treatments every 4 hours and as needed, frequent suctioning and urgent tracheostomy changes by trained providers or caregivers when he develops a mucous plug. The mother is the primary caregiver and works full time. Without overnight PDN, the patient will have to be institutionalized.

As per the available document, patient was noted to have maintained baseline requirements and patient needs oxygen flow at night and no need for BiPAP (bilevel positive airway pressure). There is no documentation how much he desaturates at night and how much respiratory decompensation he has periodically. However, for the nocturnal monitoring, approve 12 hours per night for 7 days a week PDN coverage. The daytime custodial care and medication administration can be done by caregiver. Hence denying 168 hours per week PDN but approving 84 hours per week PDN. 

Based on the above, the medical necessity for the 168 hours per week, two thousand one hundred and eighty-four (2,184) units of private duty nursing (PDN, T1000) services is not substantiated. The insurer's denial is modified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Systemic hypertension 

Treatment: inpatient admission

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

This patient is a female admitted to the hospital for systemic hypertension. She was referred by her Ear, Nose, Throat (ENT) physician to the Emergency Room (ER) for a blood pressure (BP) of 155/114 and 170/111 noted on a pre-operative clearance exam. Her pressure did not respond to an oral dose of Amlodipine and she needed treatment with intravenous (IV) Labetalol; therefore, she was admitted to the Pediatric Intensive Care Unit. After 2 doses of IV Labetalol, she was treated with Ativan due to her anxiety and her blood pressure improved. Therefore on day two she was placed on oral Amlodipine. She continued on that day to have further studies including a renal ultrasound. She continued to be stable and was discharged with some study results pending. The insurance company has denied coverage for the inpatient stay as it was not medically necessary.

MCG for Hypertension: Clinical indications for Admission to Inpatient Care States:

Hypertension in pediatric patient necessitating treatment with intravenous medication indicated by all of the following:

1)	Severe hypertension (blood pressure greater than 95th percentile for age, gender and height plus 30mmHg)

2)	 Intravenous treatment necessary indicated by 1 or more of the following.

A)	Acute or worsening target organ damage secondary to hypertension.

B)	Oral antihypertension treatment not feasible (e.g. patient not cooperative)

Based on normal blood pressure tables, the 95th% blood pressure recording for a girl at 95th% for height is 125/82. After oral Amlodipine, her blood pressure was 168/119, clearly meeting the above criteria for admission. In addition, the patient was extremely anxious and appropriately treated with IV medication. By the end of a specified date, the patient's blood pressure was well controlled on oral Amlodipine and the patient could have been discharged. Therefore, the denial is partially reversed (admission on specified dates was medically necessary). The insurer acted reasonably in their denial of coverage for the inpatient admission for specified dates, but not for other specified dates.

Based on the above, the insurer's denial of coverage for the inpatient admission is modified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Postpartum Preeclampsia 
 
Treatment: Inpatient Admission

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

This is a female patient with a medical history of gestational diabetes, hypertension, and hypothyroidism. She presented to the clinic status postpartum day 10 from a repeat cesarean section with complaints of an elevated blood pressure. Blood pressure on admission was 151/77. The plan was to obtain preeclampsia labs, administer Magnesium Sulfate, and control blood pressure. Protein in urine was positive and the patient's Lactate dehydrogenase (LDH) was elevated. Her blood pressure was monitored and controlled. She was treated with Magnesium Sulfate and discharged home in stable condition with outpatient instructions. 

This patient presented 10 days after delivery with elevated blood pressure, protein in urine and elevated LDH. Delayed postpartum preeclampsia can be defined as signs and symptoms of the disease leading to readmission more than two days but less than six weeks after delivery, although various other definitions have been used. The signs and symptoms can be atypical; for example, the patient may have thunderclap headaches alternating with mild headaches or intermittent hypertension. The risk factors for delayed postpartum preeclampsia appear to be similar to those for preeclampsia during pregnancy, but some patients have no risk factors.

The diagnosis of preeclampsia is based on the new onset of hypertension and either proteinuria or end-organ dysfunction after 20 weeks of gestation in a previously normotensive woman:
Systolic blood pressure >=140 mmHg or diastolic blood pressure >=90 mmHg, and (1 of the following)
1) Proteinuria >=0.3 grams in a 24-hour urine specimen or protein: creatinine ratio >=0.3, or

2) Signs of end-organ dysfunction (platelet count <100,000/microliter, serum creatinine >1/1 mg/dL or doubling of the serum creatinine, elevated serum transaminases to twice normal concentration).

This patient had elevated blood pressure, protein in the urine, as well as elevated LDH level. This patient did have a diagnosis of pre-eclampsia. Admission was medically necessary to control blood pressure and administer magnesium sulfate to prevent a possible seizure. However as of a specified date, the patient's blood pressure was controlled and her LDH was coming down. She has received 24 hours of magnesium sulfate and could have been discharged home on home blood pressure monitoring to return if any worsening of her blood pressure. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient on a partial basis for specified dates. The inpatient hospital admission for the first specified date range is considered medically necessary for this patient. However continuous admission thereafter was not appropriate.

Based on the above, the medical necessity for the inpatient admission for the first set of date range is substantiated and continuous admission for the subsequent dates is not substantiated. The insurer's denial is modified.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a patient with a history of nonvalvular atrial fibrillation, hypertension, diabetes, liver cirrhosis, esophageal varies and prior gastrointestinal (GI) bleeding who was referred for transcatheter left atrial appendage occlusion as part of stroke prevention given elevated risk for bleeding with anticoagulation. The health plan's determination is overturned in whole. The patient has atrial fibrillation with comorbid conditions of hypertension and diabetes. Based on his stroke risk, anticoagulation is indicated. He is also at an elevated risk of bleeding given his hypertension, prior bleeding events and liver disease. As his stroke risk warrants therapy, and his is sufficiently his, non-pharmacologic approaches to stroke prevention are warranted. The Watchman left atrial appendage occlusion device is an Food and Drug Administration (FDA) approved therapy for this indication, and compared to anticoagulation, it has been shown to be similarly effective in stroke prevention and safer with regard to bleeding. In this case, transcatheter left atrial appendage occlusion is the most appropriate therapy for this patient with atrial fibrillation, elevated stroke risk and a contraindication to long term anticoagulation. This is an inpatient procedure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Pregnancy
Treatment:  Genetic testing
The prenatal genetic testing was partially medically necessary and partially not medically necessary.  The portion of the testing panel related to spinal muscular atrophy, CPT 81401, is medically necessary.  No other portion of the complete Ashkenazi screening panel is medically necessary.

The American College of Obstetricians and Gynecologists recommends that patients who do not have a family history of a specific genetic disorder or a history of Ashkenazi Jewish ancestry be offered maternal carrier screening for cystic fibrosis and spinal muscular atrophy.  It is not recommended that such patients receive testing for the Ashkenazi-specific conditions for carrier screening because there is not clear evidence of any increased benefit to them or their pregnancies from this expanded screening.  Because this patient falls into this category, it is not medically necessary for her to receive the entire Ashkenazi panel, which in addition to a number of Ashkenazi-specific diseases also includes screening for cystic fibrosis and spinal muscular atrophy.  According to the information reviewed, no evidence was presented that she had previously been screened for spinal muscular atrophy, although the patient previously had carrier screening for cystic fibrosis.  Carrier screening testing needs to be performed only once per lifetime for any given condition because these characteristics are inherited at birth, so repeat testing for cystic fibrosis is also not medically necessary.  

However, if screening for spinal muscular atrophy has not previously been performed, then the portion of the testing panel related to spinal muscular atrophy, CPT 81401, is medically necessary.  There are no records describing that this patient has been tested for spinal muscular atrophy; therefore, this aspect of the test is medically necessary.  No other portion of the complete Ashkenazi screening panel is medically necessary.