Persius/imr-appeals huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Sickle Cell Anemia. 
Treatment: Jadenu. 

The insurer denied Jadenu.  The denial is upheld.

The patient is a This is a female with sickle cell anemia. The patient has iron overload. Jadenu has been requested but was denied, as the patient has not failed the formulary alternatives.

The health plan's determination is upheld.

There is a paucity of evidence that the formulary option, deferiprone is inferior to deferasirox (Jadenu). The former does carry the potential side effect of agranulocytosis, but this can be mitigated by following the Food and Drug Administration (FDA)-recommended weekly neutrophil counts. The patient has no documented contraindications to deferiprone therapy, such as severe liver dysfunction. The two agents have not been compared directly with regard to safety or efficacy, and both are considered reasonable options in the peer-reviewed literature (NEJM) and by the authors of UpToDate. There is no reason why the patient cannot use the formulary alternatives.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Diabetes, congestive heart failure and dementia.
Treatment:  Personal care assistance (PCA) services 24 hours per day split shift for 7 days per week.
The insurer denied coverage for personal care assistance (PCA) services 24 hours per day split shift for 7 days per week.
The denial is overturned.

This is an elderly female with chronic medical problems including diabetes, congestive heart failure and dementia. She lives alone in a 1-bedroom apartment. The insurer approved PCA services 27 hours/week. Under review is the requested increase in personal care assistance (PCA) services 24 hours per day, split shift for 7 days per week. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive status is described as "modified independent- some difficulty in new situations only." She was also able to identify an emergency plan. The patient requires maximal assistance for bathing, lower body dressing and toilet use. Extensive assistance is needed for personal hygiene, upper body dressing, and toilet transfers. She is infrequently incontinent of bowel and bladder. Extensive assistance is also reported for bed mobility and locomotion. Eating is independent. 

The treating physician's assertion of the patient's "severe dementia" is inconsistent with the UAS report of "modified independent" cognition. However, the patient's functional impairments support the medical necessity of increasing PCA services. Her cognitive status and functional needs are not at a level or unpredictable as to require the requested services 24 hours per day split shift for 7 days per week. This physician would agree the patient may require 24-hour monitoring. However, safety monitoring under personal care services does not include monitoring an individual (e.g., dementia) when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by her supportive family and increasing PCA services to 12 hours/day, 7 days/week for a total of 84 hours. 

From a physical medicine and rehabilitation perspective, the requested increase in personal care assistance (PCA) services 24 hours per day split shift for 7 days per week is not medically necessary. 

From a physical medicine and rehabilitation perspective, personal care assistance (PCA) services 12 hours/day, 7 days/week, totaling 84 hours is medically necessary.

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 personal care assistance (PCA) services 24 hours per day split shift for 7 days per week services is not substantiated. PCA services 12 hours/day, 7 days/week, totaling 84 hours is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hypertension, laceration of the right quadriceps muscle, laceration of the left quadriceps muscle, sleep apnea, sarcoidosis, and unspecified injury of the right quadriceps muscle
Treatment continued stay at the SNF (skilled nursing facility)
The insurer denied coverage for continued stay at the SNF (skilled nursing facility)
The denial is modified.

The patient was initially appropriate for the SNF level of care (1, 2, 3). His clinical condition and functional deficits were amenable to medical intervention and comprehensive rehabilitation. He participated in physical and occupational therapy with demonstrated gradual improvement.  There was significant improvement particularly for mobility after removal of the lower extremity casts and switching to hinged braces.  According to the physical therapy notes, the patient's ambulation improved from using a rolling walker 15 steps forward/backwards to ambulating 150 feet with the walker. Functional improvement during this time in occupational therapy was without significant change. Allowing additional time for rehabilitation therapy after bilateral lower extremity cast removal was clinically appropriate. However, the patient could have been transitioned to a lower level of care (e.g., long term care, home with therapy services). In addition, there were no acute medical or complicated nursing issues that required continued stay at the SNF after the first 22 days.

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty inpatient stay at the SNF for the first 22 days was medically necessity. However, the patient could have been transitioned to a lower level of care (e.g., long term care, home with therapy services) rendering continued stay at the SNF no longer medically necessary.

The medical necessity for a continued stay at the SNF services is modified. Allow continued stay at the SNF for the first 22 days. Deny continued stay.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: sinusitis.
Treatment: sinus surgery.
The insurer denied sinus surgery (CPT 31298, 31295, 31254 and 30117). 
The health plan's determination is overturned in part.  CPT codes (31298, 31295, 31254) are indicated. CPT code 30117 is not indicated.

The patient is a female with a history of recurrent sinusitis who underwent balloon sinusplasty of the paranasal sinuses and reduction of nasal swell bodies. The surgery was denied by the health plan.

The balloon sinuplasty CPT codes (31298 and 31295, 31254) are likely to be more beneficial than standard treatment because they do meet the criteria for chronic sinusitis (thickening noted on CT scan). In addition, the patient's anterior ethmoidectomy was indicated for the chronic sinus disease (noted on CT scan). However, CPT code 30117 is not likely to be more beneficial in this case. 

CPT code 31298 (CPT 31298 Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); frontal and sphenoid sinus ostia) is a proven treatment for recurrent sinusitis. This procedure, along with CPT 31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium e.g. Balloon dilation, transnasal or via canine fossa, is considered a standard treatment for sinusitis symptoms. CPT 30117 - treatment of the swell bodies of the septum - does not have sufficient randomized clinical trials on the efficacy of this treatment. There is not appropriate evidence in the literature that this treatment could be considered standard of care to treat nasal congestion.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, osteoarthritis, and dementia
Treatment: 84 hours per week of personal care aide (PCA) services, 12 hours per day, 7 days per week
The insurer denied coverage for 84 hours per week of PCA services, 12 hours per day, 7 days per week.
The denial is modified.

This patient is elderly with chronic medical problems including hypertension, osteoarthritis, and dementia. She lives "with a roommate who is bed bound." The insurer approved personal care aide (PCA) for 49 hours/week. The request is for PCA 12 hours /day, 7 days/week for a total of 84 hours/week.

The recent Uniform Assessment System (UAS) assessment report was reviewed. The patient's cognition is described as moderately impaired. She is "self-directing and is able to make needs known. Member is able to activate an emergency response in the event of any emergency." She requires extensive assistance for lower body dressing, toilet transfers and ambulation. Limited assistance is needed for upper body dressing and toilet use. She is frequently incontinent of bladder and infrequently incontinent of bowel. She is at the supervision level for personal hygiene, bed mobility, and eating. Her cognitive skills and functional ability have declined when compared to the prior UAS report. 

The combination of the patient's declining cognitive status and functional ability support the medical necessity of increasing the PCA 10 hours/day, 7 days/week, totaling 70 hours per week. Her condition and functional needs are not at a level or unpredictable as to require the requested 84 hours per week of personal care aide (PCA) services, 12 hours per day, 7 days per week. 

This physician would also agree that the patient may require additional monitoring. However, safety monitoring under personal care services 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. Based on the enclosed documents reviewed, her health and safety can be appropriately provided and maintained by the PCA services 10 hours/day, 7 days/week for a total of 70 hours/week. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. Medical Necessity is substantiated for 70 hours per week of PCA services, 10 hours per day, 7 days per week.

The insurer's denial of coverage for 84 hours per week of personal care aide (PCA) services, 12 hours per day, 7 days per week is modified. Medical Necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Prior root canal treatment.
Treatment: D2740 Crown Porcelain Ceramic Tooth #7, #8 and #9, Pre-service.
The insurer denied the D2740 Crown Porcelain Ceramic Tooth #7, #8 and #9, Pre-service.
The denial is partially overturned.

The patient is a male requesting crowns on teeth #7, #8, and #9. Teeth #7 and #9 have existing crowns. Tooth #8 has had root canal treatment and is heavily restored with fillings.

Yes, in part; D2740 Crown Porcelain Ceramic on tooth #8 is medically necessary.  However, D2740 Crown Porcelain Ceramic for teeth #7 and #9 is not medically necessary.
Tooth #8 has had a root canal treatment performed on it. It also has three composite fillings in it. These prior procedures will weaken this tooth and a crown is needed to strengthen it. The crown is medically necessary for tooth #8.

Teeth #7 and #9 already have crowns on them and they do not have any evidence of new decay. Therefore, they do not need new crowns.

Yes, in part; the health plan did act reasonably, with sound medical judgment and in the best interest of the patient in denying D2740 Crown Porcelain Ceramic for teeth #7 and #9 as it is not medically.  However, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient in denying D2740 Crown Porcelain Ceramic for tooth #8 as it is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Systemic inflammatory response syndrome (SIRS)
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is partially approved.

The patient is an adult male. He presented to the hospital with bilateral hand numbness, vomiting, dizziness, abdominal pain, urinary frequency, and chest pain. The patient's vital signs were stable: temperature 100.8, respiratory rate 17, heart rate 116, blood pressure 100/53, and oxygenation 96% (percent). His exam was unremarkable. His hand numbness had resolved. Remarkable labs: white blood cell count 16.6, hemoglobin 13, creatinine 1.12, lactic acid 2.9, sodium 129, and troponin negative. Urinalysis was positive for leukocyte esterase. Chest X-ray and head and abdominal/pelvic computed tomography (CT) scans showed no acute disease. Electrocardiogram (EKG) showed sinus tachycardia and no ischemic changes. The patient was admitted with systemic inflammatory response syndrome (SIRS). Plan of care included intravenous antibiotics and intravenous fluids. On day #2, temperature was 98.6, heart rate was 96, and blood pressure was 100/54. Intravenous fluids were increased to 125 cubic centimeters per hour for blood pressure. Plan was to continue intravenous antibiotics. On day #3 and day #4 vital signs were stable with normal blood pressure and afebrile. 
Cultures were negative. He continued intravenous antibiotics. He was cleared for discharge on day #5.

Inpatient hospital admission for day #1 and day #2 was medically necessary, however inpatient hospital admission for days #3, #4, and #5 was not medically necessary.

This patient was admitted with systemic inflammatory response syndrome. The patient presented with several complaints. The evaluation supported systemic inflammatory response syndrome: temperature over 100.4 degrees Celsius, heart rate greater than 90, and white blood cell count greater than 12. Systolic blood pressure was borderline at 100. Diagnostic studies revealed an abnormal urinalysis. These findings support inpatient admission for cultures, intravenous fluids and intravenous antibiotics. He continued to require intravenous fluid support for blood pressure on day #2. Inpatient hospital admission for day #1 and day #2 was medically necessary for further evaluation and management of systemic inflammatory response syndrome. As of day #3, he was hemodynamically stable and without evidence of bacteremia. The patient was stable for discharge. Inpatient hospital admission for day #3 to day #5 was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Infectious disease
Inpatient hospital

Diagnosis: Knee injury. Treatment: Inpatient stay. The insurer denied the inpatient stay. The health plan's determination is overturned in part.

At the time of his admission, the patient was brought to an urgent care with a one day history of right knee swelling. The day before, he fell on the porch and abraded his right knee; the next day, the mom noticed the area was swollen so she brought him to the urgent care clinic, where the temperature was reportedly 101.6. Urgent care referred him to the emergency department (ED) for evaluation of possible septic arthritis. In the ED, the patient was afebrile with heart rate (HR) 132. He could bear weight on the right lower extremity and had normal range of motion of the knee joint and normal gait. His white blood cell (WBC) was 22.7 with 81% neutrophils. Erythrocyte sedimentation rate (ESR) was 28. C-reactive protein (CRP) 4.7. Plain film and computed tomography (CT) scan of the knee were normal. He was given intravenous (IV) clindamycin in the ED and hospitalized for further IV therapy. 

The Milliman Care Guidelines for Pediatric Cellulitis specifically state that a white cell count of greater than 15,000 is an indication for acute inpatient care. The WBC for this patient was 22.7, therefore the acute inpatient care was appropriate for 1 day.
By the second hospital day, however, the patient was clinically well and had remained afebrile and hemodynamically stable. The infection (the pus pocket below the right kneecap) was spontaneously draining, did not require a surgical drainage procedure, and there was substantial clinical response after the first two doses of IV antibiotics in terms of reduction of erythema and tenderness. The treating physicians had determined that the patient did not clinically have a septic arthritis or any other systemic/deep infection requiring surgical management, prolonged IV antibiotics, and continued measurement of serum inflammatory markers. There was no evidence of bacteremia, sepsis, or SIRS (Systemic inflammatory response syndrome). The patient no longer met acute inpatient criteria after the first hospital day.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia

Treatment: Personal Care Services (PCS) 12 hours, 7 days/week, totaling 84 hours/week 

The insurer denied coverage for PCS 12 hours, 7 days/week, totaling 84 hours/week
 
The denial is modified

This is a patient with progressive Alzheimer's dementia who lives alone. The insurer approved PCS 7 hours/day, 5 days/weeks and 5.5 hours/day, 2 days/week totaling 46 hours/week and the physician is requesting PCS 12 hours,7 days/week, totaling 84 hours/week.

According to the recent Uniform Assessment System (UAS) report, the patient's cognitive status is described as "moderately impaired." She is "alert and oriented x2, very forgetful and confused at times. Member unable to make decisions independently and unable to provide consent." She requires extensive assistance for bathing. Only limited assistance is needed for personal hygiene, dressing, eating and toilet transfer/use. She is frequently incontinent of bladder and infrequently incontinent of bowel. The patient was observed ambulating without an assistance device (e.g., cane or walker).

The patient's treating physician indicated that during the day, "her current home health aide hours are insufficient, and she had times where she was left alone and tried to leave her home, or was confused, agitated and couldn't take care of herself. It is extremely unsafe for her." The physician also noted, "In the evening her daughters can take over her care, and overnight her medications keep her asleep."  

The patient's condition and functional needs are not at a level or unpredictable as to require the requested PCS 12 hours/day, 7 days/week. Given her functional decline, increasing PCS to 8 hours/day, 7 days/week (56 hours total) is medically necessary. This patient may require additional monitoring; primarily due to the concern for increased agitation, wandering and overall safety. However, safety monitoring (e.g., dementia) under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.  

Based on the above, the insurer's denial should be modified. The health care plan acted reasonably in part. 

The medical necessity for 12 hours a day 7 days a week is not substantiated, but increasing PCS to 8 hours/day, 7 days/week for a total of 56 hours/week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
 
Treatment: Continued Inpatient Detoxification Level of Care

The insurer denied the Continued Inpatient Detoxification Level of Care.  The denial was modified.      
This is a male patient who presented to a rehabilitation facility for detoxification treatment. The patient tested positive for opiates, cocaine, and tetrahydrocannabinol. His presenting symptoms included joint discomfort, restlessness, elevated heart rate, anxiety, and irritability. He admits to using intravenous (IV) heroin, tens of dollars' worth of crack, and smoking 2 blunts of cannabis daily. He has a history of Naltrexone use and it was reported that he relapsed after he stopped taking it. He had a history of depression, anxiety, including an attempted suicide, and inpatient substance detoxification and rehabilitation treatment. He was placed on a methadone protocol. The patient signed out of the facility against medical advice (AMA). 
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that patients with comorbid medical conditions complicating withdrawal, acute medical instability, or a reported history of complicated withdrawal symptoms such as delirium tremens or withdrawal seizures are in need of inpatient substance detoxification. It also states 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. 

The patient was in the facility for a total of 11 days. The first four days were approved by the insurer. After this review, one additional day was approved. All subsequent days were denied.

According to the LOCADTR he did require 24 hour treatment for the first five days as he needed detoxification medication to modify withdrawal and had a history of daily IV heroin use, which put him at high risk for overdose. He needed 24 hour treatment due to this risk, and he had past inpatient substance treatments and continued to use heroin and crack. Therefore, outpatient treatment for detoxification was not considered enough or safe as he needed 24 hour treatment for detoxification. However, as of the sixth day there were no further reports in the medical records provided stating that he still had withdrawal symptoms or that he still was in need of Methadone detoxification. 

The insurer's denial is modified. Based on the above, the medical necessity for the continued inpatient detoxification level of care for the first 5 days is substantiated. Inpatient detoxification level of care from the sixth day until the day the patient signed out AMA is not substantiated.