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

Diagnosis: Heart disease, hypertension and osteoarthritis. 
Treatment: 84 hours per week - consumer directed personal assistant services. 
The insurer denied coverage for 84 hours per week - consumer directed personal assistant services. 
The denial is modified. 

This is an elderly female with chronic medical problems including heart disease, hypertension and osteoarthritis. She lives alone in a private residence. The plan approved 45 consumer directed personal assistant services (CDPAS) hours/week and the request is for 84 CDPAS hours/week. 

In the Uniform Assessment System (UAS) report he patient's cognitive skills are described as "minimally impaired." She is reportedly totally dependent to maximal assistance for completing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires extensive assistance for bathing, lower body dressing, locomotion, toilet transfer/use and ambulation. Limited assistance is reportedly needed for personal hygiene, upper body dressing, bed mobility and eating. The patient is reportedly frequently incontinent of bladder and infrequently incontinent of bowel. Her Activities of Daily Living (ADL) status has reportedly declined over the prior 90 days. Her level of self-sufficiency has reportedly not changed over the prior 90 days. 

The letter from the patient 's treating provider nurse practitioner was reviewed. The patient's cognitive and functional status is rapidly declining. In addition, the Uniform Assessment System (UAS) report demonstrates only modest cognitive and functional decline when compared to the previous report. The patient's condition and functional deficits are not at a level or unpredictable as to require the requested consumer directed personal assistant services 84 hours/week. This physician would agree that the patient may benefit from monitoring for safety; particularly due to his decreased mobility and falls risk. Consumer directed personal assistant services (CDPAS) for companion care or safety supervision without the direct provision of task assistance is not a covered service. However, after reviewing the letter from her treating provider and the prior UAS report, this physician would agree that the patient should have consumer directed personal assistant services increased to 63 hours hours/week. 

From a physical medicine and rehabilitation perspective, the requested increase in Consumer Directed Personal Assistance Services 84 hours per week is not medically necessary. However, 63 CDPAS hours per week are 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 84 hours per week - consumer directed personal assistant services services is not substantiated. However, 63 CDPAS hours per week are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac Ablation 
Treatment: Inpatient admission 
The insurer is denied coverage for inpatient admission. 
The denial is partially overturned. 
This is a male patient with a long history of paroxysmal atrial fibrillation who has had several ablation procedures, gastroesophageal reflux disease (GERD), obesity and sleep apnea.  He was instructed by his physician to come to the Emergency Department after having had a few hours of palpitations and lightheadedness. He described the symptoms to be as similar to his previous episodes of atrial fibrillation. His presenting vital signs were: blood pressure of 141/81, heart rate of 99, temperature of 98.2 F, respiratory rate of 18, and oxygen saturation of 96% on room air. An electrocardiogram (EKG) was done that revealed sinus tachycardia. The patient's chest x-ray was unremarkable other than a small scar at the right base. The patient's laboratory test results included white blood cell (WBC) count of 8.5, hemoglobin of 14.1, creatinine of 1.1, troponin of 0.00, BNP of 12, and TSH of 1.99. The patient was admitted to the hospital and underwent an ablation and MitraClip procedure under general anesthesia. The patient's postoperative electrocardiograms (EKG)s were remarkable for diffuse ST segment elevations consistent with pericarditis. A chest x-ray was done that showed bilateral pleural effusions. The patient was discharged on pantoprazole, sulcralfate, colchicine, apixaban, amiodarone, Percocet, Colace, sennakot, miralax, multiple vitamins, magnesium oxide, and folate.

Although there is evidence that this procedure was complex enough to require post-operative monitoring in an inpatient setting, rather than in a same -day procedure area, there is no evidence that this patient required an acute inpatient level of care until the morning. This ablation procedure with MitraClip should have been scheduled electively after outpatient medical treatment of recurrent, hemodynamically stable paroxysmal atrial fibrillation. This patient did not require Emergency Department (ED) care or inpatient admission to treat hemodynamically stable paroxysmal atrial fibrillation prior to his endoscopic modified MAZE procedure without cardiopulmonary bypass. This should have been scheduled as an elective procedure.

The health plan acted reasonably with sound medical judgment to deny coverage for but did not act in the best interest of the patient to deny coverage.

Based on the above, the medical necessity for the inpatient admission is partially substantiated. The insurer's denial should be partially overturned. Medical necessity is established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cervical stenosis
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned in part.

According to the medical records, the patient with cervical stenosis was admitted and underwent posterior cervical decompression and fusion cervical (C) 3-6 without complications. Post operatively, the patient remained hemodynamically and neurologically stable, with no infection, bleeding, or infusions noted, and no further surgery needed.

"Conclusions: Posterior cervical fusion with decompression resulted in significant clinical improvement, as indicated by the changes in patient-reported outcomes. Additionally, high fusion rates and low rates of revision and of complications and adverse events were found." (Youssef, J. A., et al, 2019)

There is no indication for inpatient stay pre-operatively as the surgery could have been done electively, with admission on the day of surgery. Also, inpatient stays are allowable for up to 3 days after fusion to make sure no hardware failure and no bleeding. 

Based on the above, the insurer's denial must be overturned in part. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for full inpatient hospital admission is partially substantiated. Inpatient hospital admission for only three days are medically necessary; however, four days are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Increase in personal care aide (PCA) services: 12 hours per day, 7 days per week, for a total of 84 hours per week. 

The insurer denied coverage for increase in personal care aide (PCA) services: 12 hours per day, 7 days per week, for a total of 84 hours per week. 

The denial is modified. 

This is an elderly patient with progressive dementia. She lives alone in a private residence. The insurer approved personal care aide (PCA) 3 hours/day, 3 days/week for a total of 9 hours/week and the request is for PCA 12 hours/day, 7 days/week, for a total of 84 hours/week. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition was described as "moderately impaired- decisions consistently poor or unsafe; cues/supervision required at all times."  She is totally dependent to maximal assistance for much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  However, she requires only limited assistance for bathing, lower body dressing and toilet use. She is otherwise independent to supervision for personal hygiene, upper body dressing, eating, bed mobility, locomotion, toilet transfer and ambulation. She is also continent of bowel and bladder. The patient's clinical condition, limited physical impairments and independent mobility do not support the medical necessity of the requested PCA 12 hours/day, 7 days/ week, (84 hours/week).  However, increasing the PCA to 3 hours/day, 7 days/week is clinically appropriate. This physician would agree the patient may benefit from additional monitoring; particularly due to her cognitive deficits and wandering. However, safety monitoring under personal care services does not include monitoring an individual (with 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 more appropriately provided and maintained by increasing PCA to 3 hours/day, 7 days/week. 

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 an increase in personal care aide (PCA) services: 12 hours per day, 7 days per week, for a total of 84 hours per week services is not substantiated. However, increasing PCA to 3 hours/day, 7 days/week (21 hours/week) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/musculoskeletal
Physical therapy

Diagnosis: shoulder surgery
Treatment: Physical therapy (PT)
The insurer denied physical therapy. The health plan's determination is overturned in part. 

The patient is a male with medical history significant for left total scapulectomy for osteosarcoma with reconstructive surgery involving the use of a custom fabricated scapula prosthesis. Under review is the medical necessity of physical therapy (PT) services.

Physical Therapy was medically necessary for 2 months. After 2 months, no documentation was provided to support continued PT. The patient underwent left total scapulectomy with scar body reconstruction and rotator cuff capsular reconstruction. He had home therapy for approximately 3 weeks and then began outpatient physical therapy with direction to remain in sling for 12 weeks post-op. First off, 12-week post-op restriction to sling is very normal given this type of surgery. This restriction, though, lead to slower progress as there were limitations. Regardless of those limitations, therapy documentation did show progress. For example, despite the patient reporting increased soreness once splint had increased past 45 degrees his QuickDASH disability score had still decreased from 65 to 45%. Also, while he regressed with active range of motion (AROM) in flexion and abduction (felt to be 2/2 the increased soreness) he still improved with passive range of motion of left shoulder flexion (105 to 128 degrees) and left shoulder abduction (130 to 135 degrees). He continued to make progress as was described during re-evaluation when his DASH score further decreased to 22% and his active shoulder flexion improved from 65 to 75 degrees.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Transverse myelitis
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The determination is overturned in part.

This is a patient with well-controlled type two diabetes mellitus, hypertension, hyperlipidemia, and obesity who presented to the emergency room with lower extremity weakness. The patient also reported shocking sensations that radiated from his back down into his feet. The weakness progressed to the point where he was unable to walk. He also reported some incontinence. During his hospitalization, he was diagnosed with transverse myelitis. The transverse myelitis was appreciated on magnetic resonance imaging (MRI). The patient also underwent spinal fluid analysis that showed oligoclonal banding. The patient was treated with a five day course of intravenous Solu-Medrol. There was interval improvement in his leg strength. He was subsequently discharged to a subacute rehabilitation facility. At issue is the medical necessity of an inpatient stay.

An acute inpatient stay for the diagnosis of transverse myelitis is medically necessary in part. Transverse myelitis (TM) is considered a neurologic emergency. Acute transverse myelitis is a rare acquired neuro-immune spinal cord disorder that can present with the rapid onset of weakness, sensory alterations, and bowel or bladder dysfunction. TM can occur as an independent entity, usually as a post-infectious complication, but TM also exists on a continuum of neuro-inflammatory disorders.

The patient presented to the hospital with bilateral leg weakness and sensory changes. In a neurologic examination, the patient had less than or equal to 3/5 strength in the legs and feet. An MRI of the spinal cord showed multifocal transverse myelitis. Guidelines recommend "urgent spine imaging". The patient was then treated with high-dose intravenous glucocorticoid treatment. Per guidelines, glucocorticoid treatment should be initiated as soon as possible; there are relatively few contraindications. Thus, a clinician does not need to wait for the workup to be complete before initiating therapy. The preferred regimens are methylprednisolone (30 milligrams (mg/kg) up to 1000 mg daily) or dexamethasone (120 to 200 mg daily for adults) for three to five days. There is only support for acute inpatient hospitalization from day one of admission through day five. While the patient was noted to have a pulmonary embolism, this finding was incidental. The patient was not hypoxic and did not have hemodynamic instability on account of the pulmonary embolism. The treatment of this incidental pulmonary embolism included anticoagulation, which can be accomplished with oral medications or injectable medications, such as Lovenox; this care does not require an inpatient level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Sided weakness

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is modified.

This case involves a patient who presented to the emergency department with complaints of the inability to move their left side.  The patient has a past medical history that does include hypertension.  The emergency department note is not provided. However, the history and physical indicated they had complaints of left-sided weakness with blurry vision.  The patient was evaluated in the emergency department for a stroke and after discussing with neurology a decision was made to administer tissue plasminogen activator (tPA).  The patient did receive tPA with improvement in numbness and improve strength to the left side.  The patient had a blood pressure of 158/109 with a heart rate of 65, oxygen saturation was 97% (percent) on room air, and physical examination revealed they were alert and oriented, and in no apparent distress.  The documentation did indicate the patient was able to smile which was noted to be symmetrical and tongue was midline.  They continued to have weakness in left upper and lower extremity however it was improving.  A chest x-ray was also negative.  The physician detailed the patient was likely status post, acute cerebral vascular accident (CVA) with tPA administration.  The patient was admitted to critical care and recommended for continued monitoring.  The documentation indicated she continued with treatment that included medication and assessment.  The documentation detailed she did not have any further significant adverse events throughout the hospital stay.  The patient was noted to be stable for discharge with instruction to follow-up.

Given the documentation indicated, the patient presented with the possibility of having a stroke, and was given tPA, a 24-hour admission is warranted. However, beyond the initial 24 hours, if they recovered fully with no residual neuro deficits, then no further hospitalization is medically necessary.

The health plan acted reasonably in part with sound medical judgment in the best interest of the patient. Initial admission was necessary but extended stay was not. 

The insurer's denial of coverage for the inpatient admission is modified. Medical necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left acetabular fracture
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is approved, in part. 

This is a female patient admitted to hospital. She had placement of a vena cava filter prior to reconstruction of left acetabular fracture (pathological). Her past medical history was significant for metastatic uterine carcinoma, urethral obstruction, sepsis and deep vein thrombosis (DVT) to lower left leg. 

The patient's filter was placed and hip reconstruction was completed. She required several days to obtain satisfactory pain relief. She also required a psychiatric consult due to depression.  She was discharged to home. She had a preoperative foot drop. 

Yes, in part; the inpatient admission was medically necessary, in part.

Placement of IVC filters is a semi-elective procedure which does not require an overnight stay. The procedure was not emergent. There was the report of DVT weeks prior. The placement of the filter was to decrease the risk of thromboembolic events. It was non-complicated with no evidence of bleeding, infection or fever. Heparinization was initiated but required discontinuation prior to surgery. The IVC filter could have been placed the same day of elective surgery.

However, admission was required for the hip reconstruction. The patient's procedure was complex and extensive with blood loss. The patient had underlying chronic pain which required multimodal analgesia titration. In view of her unique medical condition, the days for the hip reconstruction were warranted. Milliman Care Guidelines (MCG) report a length of stay to be surgery plus two post-operative days. Extended is considered moderate of four to seven days (i.e., the patient's underlying morbidities). 

The patient did not require inpatient admission for IVC filters.  The medical records demonstrate no acute level services were provided. The patient was able to tolerate medications by mouth. Her vital signs were stable. She did not require treatment for other underlying medical conditions. Her hematocrit was stable. She was sufficiently anti-coagulated. No additional testing nor procedures were required. There were no extenuating circumstances to substantiate ongoing length of stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Abuse
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is partially overturned.

This is a female patient with a past medical history (PMH) of generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), panic attacks, and major depressive disorder (MDD) who was admitted with complaints of (c/o) a need for detoxification (detox) from alcohol. Her vital signs were unremarkable. The physical exam was notable for Clinical Institute Withdrawal Assessment (CIWA) 32. Lab work was notable for alcohol 213, transaminitis. Imaging studies included a chest x-ray (CXR) which showed no acute pathology. An electrocardiogram (EKG) showed normal sinus rhythm (NSR). The patient was diagnosed with alcohol withdrawal and intractable vomiting and treated with CIWA, benzodiazipines (BZDs), intravenous fluids (IVF), electrolyte repletion, and anti-emetics. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was medically necessary at an acute inpatient level of care, in part. The patient had a medical history and physical exam clinically concerning for acute alcohol intoxication in the setting of CIWA scores consistent with severe alcohol withdrawal and impending delirium tremens. This presentation was further compounded by the patient's severe agitation requiring chemical sedation, and these types of patients are not appropriate for an observation level of care due to the close clinical monitoring that is required to ensure no respiratory depression and adverse events, especially in the setting of clinical concern for seizures, delirium tremens, and intractable vomiting. Due to the patient's medical history, she required close clinical monitoring for potential intervention that could not have been safely provided at a lower level of care.
However, the patient was noted to be tolerating her diet well, the CIWA was documented to be 4, the alcohol level was less than (<) 10, and she was on a tapering does of BZDs, and thus the patient was clinically stable enough to be treated at a lower level of care for service dates. The first day of the stay was medically necessary at an inpatient level of care, and the rest of the stay was not medically necessary at an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Home Health Care. 
The insurer denied home health aide 140 hours a week. 
The denial is overturned in part.

The patient is a female with past medical history significant for dementia, anxiety, hypertension, urinary incontinence, gait abnormality, back pain, limited mobility, muscle weakness and fatigue and insomnia.
This review is for the medical necessity of an increase in Consumer Directed Personal Assistance Program (CDAP) from 56 hours per week to 140 hours a week. The patient currently has a home health aide 8 hours a day 7 days a week for a total of 56 hours a week. The patient is requesting home health aide 140 hours a week.

From the clinical tasking evaluation, it is noted the patient does require more services than last year due to functional decline. The patient requires an increase to 63 hours a week to meet her needs. However, the rest of the services which are medically necessary can be provided during the time period allotted. Additional services for "prevention of falls" for "monitoring" without services being provided are typically not covered under the terms of the plan. In order for services to be considered medically necessary, the aid must be performing a service such medically necessary activities of daily living (ADL) or Instrumental activities of daily living (IADL).