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

Diagnosis: Suicidal Ideations
 
Treatment: Continued Inpatient Admission

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

This is a male patient with a history of bipolar disease, past suicidal attempts, alcohol and heroin usage, and liver disease. He was admitted to psychiatric facility with complaints of depressive symptoms including suicidal ideation with a plan to hang himself, hopelessness and helplessness, and decreased motivation. He was treated with Depakote, Quetiapine, and Trazodone, and was discharged home.

It was reported that a few days prior to discharge the patient denied suicidal or homicidal ideation or feelings of helplessness, and was less depressed, calmer, more hopeful, and had better insight and judgment, normal psychomotor activity, appropriate behavior, and organized thinking. The patient had no reports of acute medical instability or severe withdrawal that required further hospital treatment.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and also that patients with aggression, homicidal or suicidal intent, plan, or behavior, psychotic symptoms, or severe agitation are candidates for inpatient hospitalization. 

The APA Practice Guidelines for the Treatment of Patients with Suicidal behaviors reports that patients with past suicide attempts are at high risk for suicide and that past suicide attempts are the most reliable predictors of suicide. It also reports that patients with bipolar disorder and substance use are at increased risk for suicide. 

The APA Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports also that patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital, and that observation in the hospital is appropriate to better ensure their safety. This patient was considered a high risk patient for suicide due to his past history of suicide attempts and his suicidal plan to hang himself on admission, as well as his diagnoses of bipolar disorder and comorbid substance use

It appeared that the insurer acted reasonably and with sound medical judgment and in the best interests of the patient several days prior to discharge however they did not act in the best interests of the patient before then.

Based on the above, the medical necessity for continued inpatient hospital services is partially substantiated. The insurer's denial is modified.
Appeal type: Medical necessity
Decision: Overturned


 Diagnosis: Failure to thrive

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is modified

At time of admission the patient was an infant, female born at 39-week gestation by C-section with Apgar's 8 and 8 and a birth weight of 2.268 kilograms. She has a past medical history of congenital hip dysplasia, Prader-Willi syndrome, small for gestational age and feeding difficulties. After discharge she was readmitted for failure to thrive, hypotonia, hypoglycemia and bradycardia. During this admission she was noted clinically and by modified barium swallow to have uncoordinated suck and swallow and would fatigue during attempted oral feeds. After a prolonged admission she was transferred to another hospital for intensive feeding therapy. At the time she was taking most of her Gentlease 24 feeds by nasal gastric tube (NGT) boluses. 

The treating team is appealing for the full 16 days as the somatotropin delivery was delayed and there was a lack of nursing supervision to safely discharge. In addition, the team at the current hospital states that the earliest outpatient feeding appointment at the first hospital was late August. 

This patient has Prader-Willi syndrome, hypotonia and feeding issues. During her stay at current hospital her oral intake improved yet she still required nasogastric tube (NGT) feeds. By admission the mother had already demonstrated that she could both feed the child and could administer nasogastric tube (NGT) feeds. In addition, the child had demonstrated steady weight gain on the goal volumes of her feeds without vomiting, coughing, gagging or aspirating. 

Despite the benefits of growth hormone, it is not a critical medication that cannot be stopped for several days. Once the current hospital was aware that there was a hold on the medication it was rapidly resolved through discussions with the insurance coverage. Certainly, the need for growth hormone was not urgent to merit continued admission beyond the approved days. Likewise, since this child was already feeding safely with her mother there was no justification to remain an inpatient at current hospital waiting the first available outpatient feeding therapy appointment as stated in the appeal. 

This child had consistent documented weight gain and the mother was capable of continued feeds administration without skilled nursing present. This decision was rendered after review of the detailed of the current hospital's therapy notes, the details of the prolonged hospital admission at the previous hospital and the review of the management of Prader-Willi syndrome from UptoDate cited above.

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 a continued stay rehabilitation admission is modified.  Inpatient admission is medically necessary for days 0 through 9 of admission; Inpatient admission is not medically necessary for days 10 through 16 of admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left below the knee amputation

Treatment: L5910, addition endoskeletal system, below knee, alignable system and L5962, addition endoskeletal system, below knee, flexible protective outer surface covering system

The insurer denied coverage for L5910, addition endoskeletal system, below knee, alignable system and L5962, addition endoskeletal system, below knee, flexible protective outer surface covering system

The denial is modified.

This is a patient with a left below knee amputation. The patient was seen by a certified prosthetist for a replacement left transtibial prosthesis. Under review is the medical necessity of L5910, addition endoskeletal system, below knee, alignable system and L5962, addition endoskeletal system, below knee, flexible protective outer surface covering system.

The prosthetist provides sufficient documentation to support the medical necessity of the L5910 alignable system. A new (offset) alignment was needed due to significant weight loss and changes in the patient's residual limb with risk of skin breakdown and higher-pressure points over boney anatomy. However, the medically necessity of the L5962 flexible protective outer surface is not supported as medically necessary. There is no specific support that the patient is exposed to unusually harsh climate conditions or prior prosthetic components had evidence of "corrosion due to acidic bodily fluids, the spreads of viruses by providing a widespread surface and/or corrosion due to New York's unusually harsh winter."

The health plan did not act reasonably, with medical judgment or in the best interest of the patient in this particular case. Considerations included the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendations and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and/or associations. All decisions are evidence-based.

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the L5910, addition endoskeletal system, below knee, alignable system is medically necessary. However, L5962, addition endoskeletal system, below knee, flexible protective outer surface covering system is not 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 L5910, addition endoskeletal system, below knee, alignable system is substantiated. The medical necessity for L5962, addition endoskeletal system, below knee, flexible protective outer surface covering system is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Suicidal ideation

Treatment: Inpatient mental health admission

The insurer denied coverage for continuation of coverage for inpatient mental health admission. The denial was modified.

This patient is a female was admitted to this inpatient mental health treatment in this hospital due to suicidal ideation, intent, and plan to overdose on 27 pills that she had in her possession. She had a depressed and irritable mood, low energy and anhedonia. She had a history of alcohol and cannabis use. She had diagnoses of Depressive Disorder, Generalized Anxiety and Disruptive Mood Dysregulation Disorder. She took Seroquel and Trazodone. The plans were for the patient to go to a residential treatment, but she improved and was discharged with follow up at a partial hospital program (PHP).

This reviewer disagrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital but agrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicidal intent, plan, and attempts are at high risk for suicide and that past suicide attempts are the single most reliable predictor of suicide. It also reports that patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital and that observation in the hospital is appropriate to better ensure their safety. This patient was considered a high risk patient and benefitted from remaining in the hospital and being observed and assessed for safety for at least another week without reported symptoms. 

As a result, modify the previous decision and approve coverage for continued inpatient mental health treatment in this hospital for the first date range, but deny coverage for continued inpatient mental health treatment in this hospital for the second date range. The insurer acted reasonably, with sound medical judgment, and in the best interests of the patient for one date range but not the date range thereafter.

The carrier's partial denial of continuation of coverage for inpatient mental health admission is modified. Approve the first date range. Deny the second date range.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Uterine Fibroid
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission. 
The denial is partially overturned.

This is a female patient with a history of symptomatic fibroid uterus. She was admitted to the hospital for a scheduled laparoscopic hysterectomy, bilateral salpingo-oophorectomy and cystoscopy. She underwent the procedure and experienced a blood loss of 800cc.  Patient's hematocrit dropped from 33 to 26.7 Hct to 22.6 to 22.8.
She was ambulating, tolerating regular diet and voiding without difficulty. She remained afebrile with normal vital signs. She received a dose of IV iron. She was medically stable and was discharged.

There are many ways of doing a hysterectomy. The trend has been towards less invasive procedures. Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions. Laparoscopic hysterectomies are outpatient procedures unless a complication arises. Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing, or the severity of the pain is such that admission is necessary.

According to MCG, Inpatient and Surgical Care, Laparoscopic Hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure. Inpatient stay may be needed for:
1) Surgical complications (bladder ureter or bowel injury or hemorrhage)
2) Conversion to abdominal hysterectomy
3) Complex surgery (staging of endometrial cancer)
4) Wound complications
5) Comorbidities
This patient did not have any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. Post operatively, the patient was stable. However there was concern about the significant drop in her hematocrit (as low as 22.6). Even though the patient was asymptomatic for anemia and was ambulating, admission for observation and iron infusion was necessary. However the patient has received her iron therapy. There was no evidence of more bleeding and the patient could have been discharged that day.

Based on above, the inpatient hospital admission was medically necessary. However continuous admission was not.  The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient with regard to the admission, did with regard to the continued stay.

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

The patient is a female with a past medical history significant for coronary artery disease (CAD), Non-Stemi myocardial infarction (MI), diabetes, chronic kidney disease, anxiety, post-traumatic stress disorder (PTSD) and hypertension. The patient also suffers from urinary and bowel incontinence requiring the use of adult incontinence products. Currently, the patient receives 29 hours/week of personal-care assistance service hours.
At issue is the medical necessity of the increased personal care assistance hours from 29 hours per week to 40 hours per week. The health plans determination of medical necessity is overturned in part. The requested health service/treatment of Increased Personal Care Assistance from 29 to 40 hours per week is not medically necessary for this patient however, based on the documentation provided, an increase from 29 hours/week to 34 hours/week would be medically necessary. The recommendation is based upon the following rationale: the nursing evaluation of the patient's functional abilities according to the New York Uniform Assessment system (UAs) identifies the patient required a total of 34 hours per week. The patient's physician asked for an increase in personal care assistance service hours secondary to constant change in her medical condition. Noting that the patient has multiple pinched nerves causing her difficulty with balance leading to her being unable to do most activities herself. Hours were mainly for Instrumental activities of Daily Living (IADLs) and also Activities of daily living (ADLs) including personal hygiene for an average between 4-6 hours a day. The patient is currently receiving 29 hours per week. Based upon this determination of her abilities it is determined from the review that an additional 5 hours a week for assistance with her ADLs and IADLs would be medically necessary. Additional services beyond 34 hours a week are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizophrenia, unspecified type
Treatment: Continued Acute Inpatient Mental Health Treatment for Adults 

The Continued Acute Inpatient Mental Health Treatment for Adults is medically necessary for this patient, in part. 

Specifically, the Continued Acute Inpatient Mental Health Treatment is medically necessary for an additional 16 days. Any dates of service beyond that point would require additional review and is not considered medically necessary at this time.

The patient's continued hospital stay for treatment of an exacerbation of a psychotic disorder (schizophrenia) does require the continued inpatient level services, structure, and monitoring. The patient's severity of symptoms, and inability to effectively participate in treatment at a lower level of care, persistent functional impairment, and treatment issues related to persistent symptoms of acute psychosis were clinical factors and treatment dimensions that necessitated continued acute inpatient hospital care, structure, and monitoring, as proposed. The medication treatment and safety monitoring, the support of functioning and the continued application of multimodal treatments, as well as assurance of medication adherence, were factors that did warrant the continued inpatient level treatment in view of the persistent symptoms of bizarre thought content and paranoid thinking; the patient could not have been effectively managed at a lower level of care. 

The patient's admission and continued treatment is reasonable and in the best interest of the patient. Any dates of service beyond that date require additional review. 

The patient had severe symptoms of psychosis complicated by a decline in functioning and safety issues together with a high risk for medication non-adherence due to persistent symptoms of psychosis. He had deteriorated to the point that he was a safety risk with disorganized and perceptual disturbance/paranoid thinking, and, poor insight and impaired judgment that persisted throughout his stay. Additionally, outpatient treatment had failed to prevent a relapse. Again, the patient could not have been safely or effectively managed at a lower level of care or in a less restrictive environment. The continued stay was necessary to develop a safe and clinically appropriate discharge plan and disposition that would effectively support his continued treatment.

These answers are consistent with the scientific literature and practice guideline, referenced below, as well as with instruction for this NY State mandated review and prevailing standards of medical practice.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: weakness, inability to ambulate
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned in part. 

The patient is a male with an unremarkable past medical history who presented with complaints of progressively increasing lower extremity weakness and inability to ambulate. The patient stated that his issues initially started with left upper extremity weakness that was associated with decreased grip strength. The patient said that it had been going on for at least a year or so. The patient stated that he left his job due to his left upper extremity weakness and progressive lower extremity weakness.

The inpatient stay was medically necessary for 24 days. 
Based on the nationally accepted standards of care, admission at the acute inpatient level of care is indicated in cases of severe myopathy, neuropathy, or another neuromuscular disease associated with a severe functional disability that interferes with the patient's ability to perform activities of daily living, safety concerns.
The results of the physical exam and imaging studies revealed that the patient had progressive generalized weakness and inability to perform activities of daily living requiring immediate workup and surgical intervention, which was performed during the hospital stay and described in detail in the previous section of this report.
This type of workup and surgical intervention could not have been performed at any other level of care rather than the acute inpatient level.
Having said that, the entire hospitalization was not indicated at the acute inpatient level of care. Based on the review of the medical records, the patient could have been safely discharged to a rehabilitation facility on day 24. At that time the patient was afebrile, hemodynamically stable, and did not require admission at the acute inpatient level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Status post prenatal testing.
Treatment:  Multigene Panel Test.

The insurer denied the Multigene Panel Test.  The denial is overturned in part. 

Pregnant patient received maternal genetic carrier screening with an expanded carrier screening panel.  The health plan contends that expanded carrier screening is not medically necessary unless the patient is of appropriate ethnicity for elevated risk for the diseases covered with the expanded panel.  The patient contends that carrier screening is covered under the terms "preventive care to check the health of the mother and baby during pregnancy."  No documentation is available in the information provided regarding the ethnicity of the parents nor family history regarding Fragile X related disorders or premature ovarian failure.

Yes, in part.  The multigene panel test is medically necessary, in part. 

Expanded carrier screening is not medically necessary based on the information provided, but some genetic carrier screening is medically necessary for this patient that is generally included within an expanded carrier screening panel.  Based on clinical appropriateness and known test performance in different patient populations, the American College of Obstetricians and Gynecologists has issued a practice guideline regarding the appropriateness of genetic carrier screening during pregnancy.  Genetic carrier screening is recommend for spinal muscular atrophy and cystic fibrosis for all pregnant patients, and this testing is medically necessary and generally included as part of an expanded carrier screening panel.  This testing is medically necessary.  However, any other genetic carrier screening is not medically necessary, unless the patient is known to be of an appropriate ethnic background for the diseases in question.  Fragile X testing is medically necessary only if there is a family history of fragile X-related disorders, intellectual disability suggestive of fragile X related disorders, or unexplained ovarian insufficiency or elevated follicle stimulating hormone prior to age 40.  No evidence is presented in the material reviewed that the patient was of an appropriate ethnicity nor has a family history that would meet the criteria for medical necessity for any other component of an expanded carrier screening panel than spinal muscular atrophy and cystic fibrosis.  Therefore, beyond spinal muscular atrophy and cystic fibrosis, no other genetic screening is medically necessary based on the available information.