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

Diagnosis: Multiple pain complaints
Treatment: 98941 x 12, 98942 x 4 - Chiropractic treatments

The 98941 x 12, 98942 x 4 - chiropractic treatments were medically necessary, in part.

According to the documentation, the patient is a male with a history of multiple pain complaints. However, no specific etiology is noted through the records submitted.

The patient presented to the chiropractic offices. Upon evaluation, the attending chiropractor diagnosed the patient with the following: segmental dysfunction to the head, cervical, thoracic, lumbar, pelvic and sacral regions, spinal enthesopathy, low back pain, headaches, cervical disc degeneration, as well as segmental dysfunction to the lower extremity. A course of treatment was provided to the patient by the chiropractor, which included manual manipulative treatment to the spine as well as extremity. 

Moreover, the patient underwent spinal x-rays which results as interpreted by a medical radiologist revealed cervical spine multilevel degenerative changes, worse at the C3-5 levels.

Specifically, documentation presented for review does support a trial course of chiropractic care/treatment as provided to the patient by the chiropractor. However, documentation presented by the chiropractor fails to reveal that the patient was achieving any significant objective clinical gains with the chiropractic care/treatment being provided beyond a certain point. Therefore, part of the chiropractic treatments were medically necessary, and part of the chiropractic treatments were not medically necessary.

As outlined above, documentation presented for this review would support some of the chiropractic care provided. This would include a proper history, examination performed as well as a treatment plan provided. However documentation presented by the chiropractor fails to document the necessity of the continued ongoing chiropractic care/treatment being provided beyond a certain point. The daily records fail to reveal any significant changes in pain levels through the course of chiropractic treatment with waxing and waning of the patient's complaints.
Appeal type: Experimental/Investigational
Decision: Overturned

Digestive System/gastrointestinal
Surgical Services

Diagnosis: Gastroesophageal Reflux Disease/GERD
Treatment: LINX Procedure and Full Hospital Admission
The insurer denied the LINX Procedure and Full Hospital Admission. The health plan's determination is overturned in part. The LINX procedure is indicated for this patient; however, a full inpatient admission is not.

This patient is a female with body mass index (BMI) 22.5 with a history of symptomatic gastroesophageal reflux disease (GERD) refractory to medication use (maximal proton pump inhibitor (PPI)). A 24 hour potential hydrogen (pH) study revealed an elevated DeMeester score of 21.8 consistent with GERD. Upper gastrointestinal (UGI) revealed a tiny hiatal hernia. Manometry was normal. An esophagogastroduodenoscopy (EGD) did not reveal esophagitis or Barrett's esophagitis. Under review is the LINX Procedure and Full Hospital Admission.

The LINX procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. However, a full admission is not required, or indicated.
This patient has GERD refractory to medical management. Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD in newly updated nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. The exclusions to LINX and Nissen fundoplication include BMI > (greater than) 35 in which case treatment of obesity is thought to be important for treatment of GERD. Other exclusions for LINX include Barrett's esophagus with dysplasia, age < (less than) 18 and prior gastric or bariatric surgery. This patient is not documented to have any exclusions to LINX treatment.
Although the LINX treatment is considered appropriate for this patient, this procedure is routinely performed in an ambulatory or observational setting and does not require an inpatient stay. There is nothing unique about this patient in regards to medical complexity of other co-morbid conditions that would require or support the need for inpatient stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: End stage renal disease

Treatment is personal care services (PCS), 24 hours a day, 7 days a week (live-in)

The insurer denied coverage for personal care services, 24 hours a day, 7 days a week (live-in)
 
The denial is modified

The patient is an elderly patient with chronic medical problems including end stage renal disease and receiving hemodialysis 3 days/week. She was in a skilled nursing facility. She was more recently hospitalized and underwent a gallbladder procedure and scheduled for discharge home within that week. The insurer approved PCS for 8 hours/day, 4 days/week and 5 hours/day, 3 days/week for a total of 47 hours/week. The patient is requesting personal care services, 24 hours a day, 7 days a week (live-in).

The patient was in the hospital when the Uniform Assessment System (UAS) assessment was performed and scheduled for discharge home later that week.  The patient's cognitive status is described as "minimally impaired." The patient is "able to activate PERS [personal emergency response system]. PERS is in place at home." The patient requires maximal assistance for bathing, lower body dressing, walking and toilet transfer/use. She reportedly has a urinary catheter and is continent of bowel. She requires extensive assistance for upper body dressing and bed mobility. The patient is reportedly "able to walk a couple of steps with a rollator at home."   

The patient's functional impairments and extended hospital/nursing facility stay support the medical necessity of increasing personal care services (PCS). This physician would agree the patient may require 24-hour monitoring. However, safety monitoring (e.g., for dementia) under PCW (personal care worker) services does not include monitoring an individual when no other Level I or Level II personal care service task is being provided. In addition, her condition and functional needs are not at a level or unpredictable as to require the requested personal care services, 24 hours a day, 7 days a week (live-in).  

Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by increasing PCS for 12 hours/day, 4 days/week and 9 hours/day, 3 days/week for a total of 75 hours/week.

Based on the above, the insurer's denial is modified. The health care plan did not act reasonably in part and with sound medical judgment and in the best interest of the patient. The medical necessity for personal care services, 24 hours a day, 7 days a week (live-in) services is not substantiated. 12 hours/day, 4 days/week and 9 hours/day, 3 days/week for a total of 75 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: right lower extremity pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is modified

 
The patient is an adult male who has chronic bilateral lower extremity wounds and Kaposi Sarcoma. The patient was admitted for worsening right lower extremity pain (RLE) pain, drainage and foul odor, after discontinuing his oral opioid. The patient was treated with intravenous (IV) Dilaudid and then resumed his oral opioid. IV Dilaudid was administered for three days and the patient was discharged three days later to a lower level of care for wound care. 

The inpatient hospital admission was only considered medically necessary until intravenous (IV), as needed (PRN) Dilaudid was no longer needed, and it was reported that the patient had already re-started oral opioids for pain management. 

As such, the request should be partially approved. 

Per Jafari, S., et al., (2015), "Patients who are admitted to hospital because of deep tissue infections undergo a course of intravenous (IV) antibiotic therapy until the infection is resolved. Length of treatment varies from a couple of weeks to several months depending on the infection site and severity. After the patients are stabilized within the first days to a week after admission, they often are kept in hospital mainly because of lack of other alternatives in the community to complete the course of IV antibiotic. This results in unnecessary and lengthy hospital stay."

Per Abi-Aad, K. R., & Derian, A. (2023), "Close monitoring of patients for respiratory depression is imperative, especially during the initial 24 to 72 hours of commencing the therapy and subsequent dosage adjustments with hydromorphone. The hydromorphone dosage should be modified accordingly based on the monitoring results. Patients should be regularly assessed for adequate pain relief, blood pressure, mental and respiratory conditions, bowel functionality, indications of hypogonadism or hypoadrenalism, and signs and symptoms of misuse, abuse, and addiction."                                                         

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 inpatient hospital admission is modified to reverse denial for the first three hospital days.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health 
Treatment: Outpatient Mental Health 
The insurer denied psychological testing. 
The denial is partially overturned.

At the time of service, the patient was a female referred for comprehensive psychological evaluation due to suspected bipolar disorder. She reported a very complex history of psychological problems, including depression, anxiety, substance abuse, obsessive-compulsive behavior, and disordered eating. She reported a history of sexual abuse. She also reported a history of trauma in both childhood and adulthood (e.g. [for example], father shot in the neck with resultant quadriplegia). Additionally, she endorsed current problems with insomnia. The health plan denied coverage for the evaluation due to a lack of medical necessity. The subject under review is the medical necessity for the psychological testing.

The requested service of psychological testing is medically necessary for this patient, in part. The patient has a very complex presentation with multiple historical and current problems and symptoms. A standard clinical interview would not be sufficient to address her multiple issues. Comprehensive psychological testing was clearly needed to differentiate among several diagnostic possibilities. Moreover, the diagnosis of bipolar disorder requires a careful review of the history, symptoms, course, and potential overlap with related disorders.

The records provided clearly establish the medical necessity for comprehensive psychological evaluation due to the complexity of the case and need to rule in/rule out related disorders in order to arrive at a proper diagnosis and treatment plan.
However, establishing the medical necessity of comprehensive psychological evaluation does not necessarily imply that this psychological evaluation was entirely medically necessary. The provider employed a broad array of measures, but not all of them are clearly necessary to arrive at a diagnosis and treatment plan. For example, there does not appear to be a sufficient rationale for inclusion of the following cognitive measures:

1) California Verbal Learning Test - Third Edition (CVLT-3) 2) Delis-Kaplan Executive Functioning System (D-KEFS) - selected subtests 3) Wechsler Adult Intelligence Scale - Fourth Edition (WAIS-IV)

This was not a neuropsychological evaluation, and a comprehensive assessment of cognitive functioning was not clearly supported by the history and referral questions. It is fairly common for some of these measures to be included in a comprehensive psychological evaluation, but the present one did not clearly provide a rationale for cognitive assessment, and these measures were not medically necessary to rule in or rule out plausible alternative diagnoses.

This patient clearly needed a comprehensive psychological evaluation, and this is fully supported. 

As such, it would be reasonable and medically necessary to overturn the portion of the psychological evaluation medically necessary to arrive at a proper diagnosis and treatment plan.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Anemia and electrolyte disorder.
Treatment:  Inpatient admission.

The insurer denied coverage for an inpatient admission.  The denial is overturned in part.

The is a patient with a history of tobacco abuse, diabetes, angioedema, daily alcohol use, corneal ulcer transplant, hypertension, chronic kidney disease (CKD) stage V (5), and peripheral vascular disease (PVD) with fifth toe amputation. She had a calcium level of 6, hemoglobin (hgb) of 6.7, and creatinine of 3.52. Her baseline hgb was between 6-7. She was transfused 2 units of packed red blood cells (pRBC) and her Hgb went up to 8. Calcium and magnesium were replaced intravenously (IV). She was hydrated. 

Based on the records provided for review the inpatient days 1 and 2 were medically necessary to complete hydration and transfusion and to assess kidney function, Calcium and electrolytes after IV fluids. On the following day, oral replacement could have been done while closely following as an outpatient or observation level. Therefore, inpatient days 1 and 2 were medically necessary; however, inpatient days 3 to 4 are not medically necessary.

O'Neill W. C. (2016), "Hypocalcemia is common in advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD), and it is standard practice to correct this back to the normal range, presumably to prevent symptomatic hypocalcemia and help control hyperparathyroidism. However, there are few studies to support this approach, and recent data suggest that this promotes vascular calcification and adynamic bone disease. Whether setting a lower target will improve outcomes has not been tested, but existing data suggest that this may have minimal risks and substantial potential benefits and should be explored."

Schafer, A.L., and Shoback, D.M. (2016), "Treatment of hypocalcemia depends on severity and chronicity. A calcium infusion is indicated for severe acute and or symptomatic hypocalcemia, while the standard mainstays of oral therapy are calcium supplements and activated vitamin D metabolites."

Beyer, A., Rees, R., Palmer, C., Wessman, B. T., & Fuller, B. M. (2017), "One-hundred twenty-four (60.8%) patients were transfused packed red blood cells (PRBC) in the ED (emergency department). The mean pre-transfusion hemoglobin level was 8.5 g (grams) /dl (deciliter). There were 73 patients with a hemoglobin value 10 g/dl; 19 (26.0%) received a PRBC transfusion. A total of 54 (26.5%) patients were transfused platelets. The main indications were thrombocytopenia (27.8%) and neurologic injury (24.1%). Ten patients had a platelet level <10,000 (guideline recommended threshold for transfusion to prevent spontaneous hemorrhage). The mean platelet count for neurologic injury patients was 197,000 prior to transfusion. The primary outcome occurred in 26 control patients (12.7%), as compared with 28 cases (13.7%). 

The insurer's denial of coverage for the inpatient admission is modified. Allow inpatient days 1 and 2, but uphold denial of days 3 to 4 as not medically necessary. Medical Necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Abdominal and pelvic pain.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is overturned in part. 

This woman presented to an outside hospital with abdominal and pelvic pain. Her recent history was notable for admission with bacteremia (S.agalactiae) that required treatment with Levaquin.

Workup showed occlusion of the inferior mesenteric artery, raising concern for bowel ischemia. Moreover, both echocardiogram and computed tomography (CT) showed possible dissection of the aortic root, raising concern for endocarditis. Additional imaging was recommended.

The patient was transferred to another facility.  On arrival, she was stable but had suprapubic pain and nausea, symptoms that she attributed to being hungry. She was admitted for monitoring because of need to rule out endocarditis and/or aortic dissection. A repeat echocardiogram was suboptimal but showed no dissection at the aortic root. Ejection fraction and cardiac motion were normal. The patient was now asymptomatic with stable vital signs.

Yes, in part; the inpatient admission was medically necessary for admission day one.  However, no, in part; the inpatient admission was not medically necessary for admission day two.

The patient presented with a clinical picture concerning for endocarditis complicated by embolization to the inferior mesenteric artery (IMA). She had a history of recent bacteremia and presented on this occasion with abdominal pain.  Computed tomography (CT) showed inferior mesenteric artery (IMA) occlusion. Both computed tomography and echocardiogram raised concern for aortic root dissection. This picture can be explained by endocarditis and embolization to the inferior mesenteric artery (IMA). Even though the patient was stable when she presented to Montefiore, inpatient admission was warranted because of the legitimate concern for endocarditis complicated by embolization. This medical condition demands inpatient hospital stay because patients can rapidly deteriorate.

In contrast to the conclusion reached by the health plan, the admission day one was medically necessary. It is true that the patient was hemodynamically stable. However, she had history, symptoms and outside imaging concerning for endocarditis with embolization to the inferior mesenteric artery (IMA). 

By admission day two, there was no longer concern for endocarditis with embolization to the inferior mesenteric artery (IMA). The health plan's conclusion that the patient did not need inpatient stay was reasonable for admission day two.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Oppositional defiant disorder (ODD)

Treatment: Inpatient care

The insurer denied coverage for Inpatient care

The denial is modified.

 
This teenager was admitted to inpatient mental health treatment due to mood and behavioral symptoms including mood swings, emotional dysregulation, oppositional defiant behavior, agitation, property destruction, self-injurious behavior including hitting self, lying, stealing, using profanities, talking about drugs, disrespectful behavior towards others, physical altercations, risky behaviors, impulsive behaviors, and difficulty following rules. He had a diagnosis of Oppositional Defiant Disorder (ODD) and attention-deficit/hyperactivity disorder (ADHD). He took Risperidone and Lamictal and attended group, individual, and family therapy. 

The Milliman Care Guidelines (MCG) Residential-Behavioral Health Level of Care- Psychiatry Child/Adolescent guidelines report that one needs to have continued danger to self or others, moderately or severe psychiatric or behavioral symptoms requiring 24-hour daily treatment, or serious dysfunction in daily living. The InterQual Behavioral Health Child/Adolescent Psychiatry Inpatient Level of Care residential treatment guidelines reports that one still has psychiatric or behavioral symptoms that put the patient at high risk for hospitalization if not in this 24-hour treatment, that they still have psychiatric or behavioral symptoms that are improving or expected to improve but they are not clinically stable yet. It also states that one could still have symptoms including disorganized behavior, command auditory hallucinations decreasing in frequency, delinquent behavior, still have a major depressive episode with certain symptoms including hopelessness, have high risk sexual behavior, eating disorder symptoms requiring 24-hour treatment, hypomanic symptoms associated with poor impulse control, or psychomotor agitation. 

In this case this patient did have continued reported psychiatric symptoms that were improving or expected to improve but were not clinically stable yet. He was considered at risk for worsened behavioral and mood symptoms if not in this inpatient therapeutic supervised and structured residential treatment due to his limited coping skills and problems solving skills, limited ability to regulate his emotions, and risky and impulsive behavior putting himself and others at risk including agitation, property destruction, self-injurious behavior including hitting self, stealing, physical altercations, risky behaviors, impulsive behaviors, and difficulty following rules. 

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 residential mental health treatment is partially substantiated but the insurer's denial is upheld in part.