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

Diagnosis: low back pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is modified

This adult female with a history of morbid obesity (BMI (Body mass index)=53) had an acute episode of low back pain and was unable to walk and do her activities of daily living (ADLs).  She was transported by ambulance to the Emergency Room and was given Intravenous (IV) Morphine which did not reduce her pain and caused nausea.  She was admitted and given non-steroidal anti-inflammatory (NSAIDs) and oral opiates.  Admission noted acetaminophen and prn (as needed) lidocaine patches. A magnetic resonance image (MRI) was ordered, and an Epidural steroid injection was administered on Day 4 of her admission. The MRI showed spinal stenosis, ligamentum flavum hypertrophy and resolution of previously documented herniated disc.

The patient had RED Flags symptoms and was administered intravenous opiates initially. However, was subsequently switched to oral medications and by Day 3 the progress note states "pain much improved, previously not able to sit straight up. Now able to walk with improved pain. Pending open MRI today than steroid injection."  

Clinical practice guidelines (1) support admission when there are Red Flag symptoms.
Casazza (2) reviewed concerning symptoms (Red Flags) that should prompt aggressive treatment.  The patient had motor weakness in being unable to ambulate:
"Certain red flags should prompt aggressive treatment or referral to a spine specialist, whereas others are less concerning. Serious red flags include significant trauma related to age (i.e., injury related to a fall from a height or motor vehicle crash in a young patient, or from a minor fall or heavy lifting in a patient with osteoporosis or possible osteoporosis), major or progressive motor or sensory deficit, new-onset bowel or bladder incontinence or urinary retention, loss of anal sphincter tone, saddle anesthesia, history of cancer metastatic to bone, and suspected spinal infection. Without clinical signs of serious pathology, diagnostic imaging and laboratory testing often are not required."

However, the full in-patient hospital Admission was not medically necessary.  As noted by Day 3 the patient was improved, ambulating with improved pain.  It was NOT medically necessary to remain an inpatient while awaiting magnetic resonance imaging (MRI) and an Epidural Steroid injection while taking oral medications.  

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 admission for 3 days is substantiated. However, continuing admission after three days is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe diarrhea. 

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is modified. 

This is a pregnant female patient who presented to the Emergency Room (ER) with severe diarrhea. She was 19.3 weeks pregnant. She had been recently diagnosed with  clostridium difficile (C. diff) and received a 10 day course of Flagyl. Symptoms did not significantly improve. A repeat stool sample was negative. Her physical examination was unremarkable. Vital signs were stable. She was hemodynamically stable with no evidence of leukocytosis. She was admitted for intravenous (IV) hydration and a Gastroenterology (GI) consult. During the admission, the patient was treated with IV magnesium sulfate for a magnesium level of 1.8. PlasmaLyte was given. Oral vancomycin was started. Progress note on day 2 of admission documented improvement in the patient's condition. Magnetic Resonance Imaging (MRI) did not show any anomaly. Progress note on day 3 of admission documented that the diarrhea resolved. Per Internal Medicine, the patient could be discharged. Per GI, the patient could be discharged. Progress note on day 4 of admission documented the patient was stable. She was discharged later that day.

This patient presented with diarrhea. Her C. diff had already been treated and stool culture was negative. There was no evidence of fulminant colitis, hypotension or shock, ileus, or megacolon. While there were concerns about a megacolon and due to the severity of the diarrhea and evidence of dehydration, admission was medically necessary to hydrate the patient, correct the electrolyte imbalance, and rule out megacolon. However, by day 2 of admission, the patient's condition had improved, and the MRI did not reveal any anomaly. There was no evidence of fulminant colitis and the patient was stable and could have been discharged home that day on oral vancomycin.

The health care plan acted reasonably in part.

The inpatient hospital admission on day 1 of admission is considered medically necessary for this patient. Continuous admission was not.

The insurer's denial of coverage for the inpatient hospital admission is modified. Allow day 1 of admission but uphold denial of day 2 to day 4.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease.
Treatment: Consumer directed personal assistance services (CDPAS) 24 hours per day, 7 days a week - split shift.
The insurer denied coverage for CDPAS 24 hours per day, 7 days a week - split shift. 
The denial is modified.

This is a patient with chronic medical problems including Alzheimer's disease. She lives with her son in a private 2-story residence. The patient is currently approved by the insurer for CDPAS 70 hours/week and is requesting an increase of CDPAS to 24 hours/day, 7 days a week - split shift.

According to the Uniform Assessment System (UAS) report, the patient cognition is described as "severely impaired." The patient requires maximal assistance for bathing. Extensive assistance is required for dressing, personal hygiene, toilet transfers and ambulation (uses a cane). She requires only supervision for bed mobility and eating. The patient is frequently incontinent of bowel and bladder. The patient's functional status is much the same as it was recorded in the prior UAS report, with modest decrease in cognition, bathing, ambulation and toilet transfer. The combination of the patient's cognitive deficits and functional impairments support the medical necessity of increasing CDPAS to 84 hours/week. Her condition and functional needs are not at a level or unpredictable as to require the requested (CDPAS) 24 hours/day, 7 days a week - split shift. This physician would agree the patient may require 24-hour monitoring, particularly due to her episodes of wandering. However, safety monitoring 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 enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by the increasing CDPAS to 84 hours/week.  

From a physical medicine and rehabilitation perspective, the requested increase CDPAS 24 hours per day, 7 days a week - split shift, is not medically necessary.  However, increasing CDPAS to 84 hours/week is medically necessary.  

The insurer's denial of coverage for consumer directed personal assistance services (CDPAS) 24 hours per day, 7 days a week - split shift is modified. Medical Necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: left total hip replacement

Treatment: inpatient hospitalization

The insurer is denied coverage for inpatient hospitalization.

The denial is modified. 

This male patient has a history of cholecystectomy, hernia repair, asthma, Crohn's disease, psoriatic arthritis, chronic back pain, Lyme disease.

The records show the patient's post surgical course was complicated by pain. He required intravenous (IV) Morphine on several occasions. The medication was provided on post surgical day #1 and #2. His dizziness and inability to be mobilized should be taken into consideration to substantiate the admission. He was not able to be treated at a lower level of care. His pain was not manageable with oral analgesics. He would not be able to receive the multiple dosages of Morphine at a lower level of service. His condition had improved and was ready for discharge. Thus, the health plan acted reasonably in part.

Based on the above, the denial of the inpatient hospitalization is modified. Reverse denial of inpatient stay 2 days and uphold denial of 2 days.  

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospitalization is modified.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Paranoid Schizophrenia 

Treatment: Continued Inpatient Hospital Admission

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

This is a male patient who was admitted to the hospital for inpatient mental health treatment for psychotic symptoms that included hallucinations, disorganized thinking and behavior, paranoid delusional thoughts, suicidal ideation, talking to himself, and poor activities of daily living (ADL). He had a history of schizophrenia and past psychiatric hospitalizations. The patient was started on Zyprexa and Depakote, and he verbalized feelings of improvement. The patient was discharged home with instructions 
to follow up with aftercare.

The APA Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior, or inability to adequately care for basic needs are candidates for hospitalization. 

Notes reported that his self-care improved, sleep improved, he had brighter affect and was calmed and was not talking to self-according to a note on that date. Two days after admission there were no further reports of significant psychotic symptoms, severe depressive symptoms, homicidal or suicidal ideation, plan or intent, and there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24 hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting.

This reviewer disagrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital from the day of admission and the following day, but agrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital for the days thereafter.

Based on the above, the medical necessity for the continued inpatient hospital admission is not substantiated. The insurer's denial is modified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: home care/personal care - level 2 personal care services (PCS), per 15 minutes increase to 24 hours per day (split shift)
The insurer denied coverage for home care/personal care - level 2 personal care services (PCS), per 15 minutes increase to 24 hours per day (split shift)
The denial is modified.

This is an elderly patient who lives alone in a 2-bedroom apartment, 9th floor, the son visits every day and stays until next morning. The son indicates he cannot do so on an ongoing basis.

The Uniform Assessment System (UAS) was reviewed. Cognition is moderately impaired decisions are consistently poor or unsafe, and the patient is oriented to person/place. The patient does not know how to activate Personal Emergency Response Services (PERS) due to cognitive decline. Regarding instrumental activities of daily living (IADL) the patient is totally dependent for meal preparation, housework, managing finances, maximal assistance for medications. 

Regarding Activities of Daily Living (ADLs) the patient is maximal assist for bathing, lower body dressing, locomotion, toilet use and transfer. The patient is extensive assist for personal hygiene and upper body dressing. The patient is independent for bed mobility and eating. The patient is frequently bladder incontinent - daily but some control - and infrequently bowel incontinent. The patient is maximal assist for locomotion and toileting. Wandering is noted as not present. No falls in last 90 days. No Emergency Room visits or inpatient overnight stays.

The patient's cognitive and functional deficits are not at a level or unpredictable as to require the requested level 2 Personal Care Services (PCS) 24 hours per day (split shift). However, the combination of the patient's cognitive deficits and functional decline support the medical necessity of increasing personal care services PCS to a live-in Personal Care Aide (PCA), 24 hours per day, which is more appropriate as they are likely capable of providing for the patient's functional needs with the ability to consistently obtain uninterrupted 5 hours of sleep. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained at home by increasing level 2 PCS 24 hours/day, 7 days/week (live-in).

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient given the need for maximal assistance with toileting, transfer, and locomotion.

Home care/personal care - level 2 personal care services (PCS), per 15 minutes increase to 24 hours per day (split shift) is not considered medically necessary, but live-in PCS 24 hours/day for 7 days is medically necessary.

Based on the above, the insurer's denial must be modified to allow live-in PCS 24 hours/day 7 days per week for home care/personal care services (PCS).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dehydration.
Treatment:  Inpatient Stay.

The insurer denied the inpatient stay.  The health plan's determination is partially overturned.

The patient is an autistic male who was brought to the emergency department with vomiting for four days and progressively decreased oral intake and number of wet diapers. The patient's vital signs were normal. The patient appeared tired. The patient's mucus membranes were dry. The patient's throat appeared red and intravenous (IV) fluids were given to hydrate, because the patient was "refusing fluids".
The patient's bicarbonate level was 16. The patient's urine specific gravity was more than 1.030. His glucose was 58. The patient was given a Normal Saline bolus in the emergency room. The patient's glucose increased to 86. He was admitted to the hospital. On arrival to the pediatric floor, the patient had normal vital signs, and was described as well appearing and sleeping comfortably. He had no vomiting or diarrhea while hospitalized and by the next day, he was starting to drink and improving. 

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient.

This patient was dehydrated based on his history (vomiting, no intake, no urine output for about 12 hours prior to arrival in the emergency department (ED)); physical findings (dry mucus membranes); and laboratory studies (bicarbonate 16, very concentrated urine). He was refusing oral fluids in the emergency department both before and after his Normal Saline IV bolus, so it was appropriate to admit him to the hospital for further IV therapy until he started to take fluids orally. His progress was likely complicated by his autism. The one day hospitalization was medically necessary, and he was appropriately discharged when he started to take oral fluids. The rest of the inpatient days were not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pancreatic cancer

Treatment: Level 2 personal care services, per 15 minutes increase to 76 hours per week

The insurer denied coverage for Level 2 personal care services, per 15 minutes increase to 76 hours per week

The denial is modified

 
This is a patient recently diagnosed with pancreatic cancer and has scheduled chemotherapy treatments.  She lives alone in a private residence.  The insurer approved personal care services (PCS) level 2; 42 hours/week and the request is for PCS level 2; per 15 minutes increase to 76 hours per week.

According to the Uniform Assessment System (UAS) report, the patient's cognition is modified independent.  She is reportedly totally dependent to maximal assistance for much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  She reportedly requires maximal assistance for bathing, lower body dressing, and toilet use.  Extensive assistance is reportedly needed for personal hygiene, upper body dressing, locomotion, toilet transfer and ambulation.  However, she was observed "walking with an unsteady gait and a cane in doors."  She is independent for eating and bed mobility.  The patient is reportedly frequently incontinent of bladder and infrequently incontinent of bowel.   Her activity of daily living (ADL) status and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days.  She has also fallen on multiple occasions over the past 90 days.  However, the patient's functional ability is described as much the same when compared to the prior UAS report. 

Based on the enclosed documents, the patient's clinical and functional deficits are not at a level and unpredictable as to require the requested PCS 76 hours/week.  Given the patient's reported diagnosis, anticipated treatment and progressive general weakness/debility, she may benefit from additional safety monitoring.  Safety monitoring under personal care services (PCS) does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.   However, the patient's current condition, level of debility and likely progression does support increasing PCS to 60 hours/week.  Based on the records reviewed, the patient's health and safety are more appropriately provided and maintained by increasing PCS level 2; 60 hours/week.   This physician also recommends reassessment in approximately 90 days, given the likely progression of her clinical condition and functional impairment.  

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 Level 2 personal care services, per 15 minutes increase to 76 hours per week is not substantiated. However, increasing PCS level 2; per 15 minutes increase to 60 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer, cerebellar metastases
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is modified, two inpatient days are approved.

This is a patient with a history of breast cancer with metastases, deep vein thrombosis (DVT), diabetes, COVID (Coronavirus), rheumatoid arthritis, steroid myopathy, and urinary incontinence for 4 years. She had a resection of cerebellar metastasis 4 years ago. The patient presented to the hospital from a skilled nursing facility (SNF) with complaints of left facial numbness, diplopia, and tongue numbness. Magnetic resonance imaging (MRI) of the brain showed cerebellar metastases. During the admission, the patient was seen by Breast Medicine, Neurology, and Radiation Oncology consulted over the case. During the admission, the patient was treated with pantoprazole, potassium chloride, simethicone, pregabalin, memantine, apixaban, dexamethasone, atorvastatin, lisinopril, and sliding scale insulin. 

The clinical presentation justified the admission while new metastases, leptomeningeal disease, or stroke were being investigated or ruled out. Her neurological symptoms have been present since external beam radiation therapy (EBRT); the only new symptom was facial numbness, which resolved.

As such, the first and second day of admission is appropriate. Ongoing admission was not medically necessary.      

"Brain metastasis, which commonly arises in patients with lung cancer, breast cancer and melanoma, is associated with poor survival outcomes and poses distinct clinical challenges. The brain microenvironment, with its unique cell types, anatomical structures, metabolic constraints and immune environment, differs drastically from microenvironments of extracranial lesions, imposing a distinct and profound selective pressure on tumour cells that, in turn, shapes the metastatic process and therapeutic responses." (Boire A., et al, 2020)

"Acute stroke is a leading cause of morbidity and mortality in the United States. Acute ischemic strokes have been classified according to The Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification system, and this system aids in proper management. Nearly every patient who presents to a hospital with acute stroke symptoms has some form of emergent imaging. As such, imaging plays an important role in early diagnosis and management." (Knight-Greenfield A., et al, 2019)

"Metastasis, involving the spread of systemic cancer to the brain, results in neurologic disability and death. Current treatments are largely palliative in nature; improved therapeutic approaches represent an unmet clinical need." (Valiente M, et al, 2018)

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. The medical necessity for the full hospital admission is modified. The admission for two days is medically necessary. The continued admission beyond two days is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease, sciatica, severe arthritis, diabetes with vascular complications. 

Treatment: Personal care services (PCS) of 24 hours per day, 7 days per week (live-in). 

The insurer denied coverage for personal care services (PCS) of 24 hours per day, 7 days per week (live-in). 

The denial is modified. 

This is a patient with multiple medical problems including paraplegia, chronic obstructive kidney disease (COPD), kidney disease, and coronary artery disease.  She lives alone in a 1-bedroom apartment.  The patient currently has Personal Care Services (PCS); 10 hours/day, 7 days/week for a total of 70 hours.  Under review is the request for increase Personal Care Services (PCS); 24 hours/day, 7 days/week (live-in). 

According to the Uniform Assessment System (UAS) report, the patient requires maximal assistance for activities of daily living that include bathing, dressing and toilet use.  She is incontinent of bowel and bladder.  Bed mobility is independent; however, she is non-ambulatory and wheelchair dependent.   Cognitive status is intact, with good short- and long-term memory.  The office visit notes from the patient's treating physician were also received, documenting her functional decline.  While cognitively intact, the patient's functional decline supports an increase in Personal Care Services.  This physician recommends increasing PCS to 12 hours/day, 7 days/week for a total of 84 hours in order to allow the patient to continue living safely at home. 

The healthcare did not plan acted reasonably, with sound medical judgment or in the best interest of the patient. 

From a physical medicine and rehabilitation perspective, the requested increased Personal Care Services (PCS); 24 hours/day, 7 days/week (live-in) is not considered medically necessary for this patient. 

From a physical medicine and rehabilitation perspective, increasing Personal Care Services (PCS); 12 hours/day, 7 days/week for a total of 84 hours is considered medically necessary for this patient. 

The insurer's denial of coverage for Personal Care Services of 24 hours per day, 7 days per week (live-in) is modified. Medical Necessity is substantiated for 12 hours/day, 7 days a week.