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

Chest Pain
Inpatient Hospital

The patient is a man with hypertension (HTN), diabetes and tobacco use who was admitted with chest and epigastric pain over 2 days prior to admission. Pulse was 53 beats per minute (bpm), blood pressure (BP) was 146/ 89 and respirations 20. An electrocardiogram (EKG) showed sinus bradycardia and no acute ST-T changes. He was admitted and ruled out for myocardial infarction with negative serial troponin levels. An echocardiogram (ECHO) showed an ejection fraction (EF) of 65%. He underwent a stress myocardial perfusion study which was abnormal.
A cardiac catheterization was performed showing a 70% mid left anterior descending stenosis. Angioplasty and stenting were performed to this vessel. There were no other significant coronary lesions. The evening following the procedure, he was noted to be borderline hypotensive, with MAP 63, and a bolus of 500cc of NS was given. He stabilized and was discharged, on aspirin, Brilinta, Imdur and rosuvastatin.
The inpatient stay is under review.

The health plan's determination is overturned in part. The patient presented with chest pain, and although he ruled out for myocardial infarction, he did have an abnormal stress test indicating myocardial ischemia. At this point, further investigation with coronary angiography is indicated. He underwent this procedure and was found to have a significant stenosis of the left anterior descending. Percutaneous coronary intervention was appropriately performed. Inpatient admission was indicated for evaluation of chest pain, with need for subsequent cardiac catheterization once stress MPI (Myocardial Perfusion Imaging) was abnormal.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: including hypertension, coronary artery disease, arthritis and Alzheimer's disease.

Treatment: PCA (personal care aide) level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week.

The insurer denied coverage for PCA level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week.

The denial is modified.

This is a patient with chronic medical problems including hypertension, coronary artery disease, arthritis, and Alzheimer's disease.  She was recently hospitalized on 2 occasions due to falls; one episode resulted in a femur fracture.  The patient is currently in a skilled nursing facility for short-term rehabilitation services.  According to the Uniform Assessment System (UAS) report, the patient's cognition is described as "severely impaired."  She requires maximal assistance for bathing, dressing, locomotion, eating, and toilet transfers/use.  She is occasionally incontinent of bowel and bladder.  Extensive assistance is needed for bed mobility and ambulation.  The patient's functional ability has declined since the UAS report, essentially for every aspect of her activities of daily living. However, the enclosed physical and occupational therapy notes from the skilled nursing facility demonstrate modest functional improvement.    

The patient's severe cognitive deficits and functional impairments support the medical necessity for increasing the PCA services to 12 hours/day, 7 days/week totaling 84 hours.  Her condition and functional needs are not at a level or unpredictable as to require the requested PCA level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week.  This physician would agree the patient may require 24-hour monitoring.  However, safety monitoring (e.g., for 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 enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by increasing the PCA services to 12 hours/day, 7 days/week totaling 84 hours.  

From a physical medicine and rehabilitation perspective, the requested PCA level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week, is not medically necessary.  However, increasing the PCA services to 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 aide (PCA) Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week services are not substantiated. However, increasing the PCA services to 12 hours/day, 7 days/week totaling 84 hours is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Asymmetry
Treatment: Masculine top surgery revision codes (13101. 13102, 14000, 14001, 15771 and 15772) consult for in-network coverage for an out of plan referral to Dr. Anandev Gurjala to be done at Marin General Hospital in Greenbrae, CA 
The insurer denied: Masculine top surgery revision codes (13101. 13102, 14000, 14001, 15771 and 15772) consult for in-network coverage for an out of plan referral to Dr. Anandev Gurjala to be done at Marin General Hospital in Greenbrae, CA 
The denial is: Overturned in part

The patient is a female to male transgender patient who underwent gender confirming mastectomies and now complains of asymmetry with too much tissue removed on one side and not enough removed on the other side. Despite the surgery he continues to bind his chest. 
On physical examination there were healed periareolar incisions with bilateral chest contour deficits more so on the right and areolar skin creases also greater on the right and bilateral lower pole skin redundancies. An undated photo shows a deflated left breast with redundant lower pole skin/skin fold and right partially deflated breast. This is clearly outside the wide range of "normal" appearance determined by referencing the gender with which the patient identifies. Another set of undated photos show a slight indent on the left at 4 o'clock, minor excess lower pole breast tissue on the right, a significant right central mound depression, a basically normal male chest appearance without excess skin with the arms raised overhead, acceptable male appearing left chest with the arms down and normal male torso contour. The subject under review is the medical necessity for masculine top surgery revision codes (13101. 13102, 14000, 14001, 15771 and 15772) consult for in-network coverage for an out of plan referral to Dr. Anandev Gurjala to be done at Marin General Hospital in Greenbrae, CA medically necessary for this patient.

Based on the photos in the reviewed materials surgery on the left chest is not medically necessary because the left chest is inside the normal range of appearance for a male chest however, the right chest is outside the normal range of appearance for a male chest. Therefore, surgery on the right is medically necessary to create a chest contour within the normal range of appearance for a masculine chest.
13101 and 13102 are not medically necessary because they are global to/covered by 14001. Normal appearance on the right will require redistribution of the remaining subcutaneous tissue from the lower pole to the central mound. This will require 14001 and 15771 and 15772. Therefore, 14001, 15771 and 15772 on the right are medically necessary but surgery on the left and 14000 are not medically necessary. It is further not medically necessary that the patient have this performed by out of network physician Dr. Gurjala at Marin General Hospital.
Appeal type: Medical necessity
Decision: Overturned

This patient was admitted to inpatient mental health treatment after going to the emergency department for syncope as she had reported bizarre behavior, auditory hallucinations, mumbling to self, paranoid delusional thinking, disorganized thinking, non-compliance, suicidal ideation, self-injurious behavior including cutting self, agitation, restlessness, poor impulse control, judgment, and insight. She had a diagnosis of Schizophrenia. She had past reported psychiatric hospitalizations. She took Risperidone, Prolixin, Depakote, and Klonopin.

The insurer denied coverage for continued inpatient mental health treatment. The decision was modified.

The American Psychiatric Association Practice Guidelines for the Treatment of Patients with Schizophrenia reports that the least restrictive level of care for safe and effective treatment is appropriate and also reports that patients with hallucinations, delusional or disorganized thinking or behavior, suicidal or homicidal intent or plan, or severe agitation or aggression are candidates for inpatient treatment. The denial was partially approved because the patient still had reports of disorganized thought process and illogical thought process as well as poor judgment and insight so she still had psychotic symptoms which required continued inpatient psychiatric hospitalization. The subsequent days of the admission were denied because there were no notes reporting hallucinations, delusional thinking, illogical or disorganized thought process, suicidal or homicidal ideation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Sickle cell crisis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is modified

The patient has the medical diagnosis of sickle cell anemia (SCA) and rheumatoid arthritis (RA). The patient's noted with sickle cell, history of (h/o) hip replacement, RA, and tested positive for Covid and was being treated with amoxicillin. The patient came to the emergency room (ER) with right (R) elbow, left (L) shoulder, and left (L) scapula, and chest pain. The patient vomited oxycodone and went on intravenous (IV) pain medication. In the emergency room (ER) she received 3 doses of intravenous (IV) Dilaudid and one dose of IV Toradol. The next day she received a total of 7 doses of IV Dilaudid. By four days later, the pain completely resolved. The treating provider is requesting plan approval for inpatient admission.

The patient's sickle cell pain is hard to evaluate, especially in a patient with resolving Covid-19 infection. As such, it is determined that for three days, an inpatient stay was reasonable and appropriate. The inpatient stay was needed especially once the patient could not tolerate oral oxycodone. The pain resolved by the fourth day and the patient could have been discharged on that day. 

The request is modified and partially approved. 

"Acute pain of SCD (sickle cell disease) is caused by vaso-occlusive crisis (VOC), impaired oxygen supply or infarction-reperfusion tissue injuries. In VOC, inflammatory cytokines include tryptase activate nociceptors and transient receptor potential vanilloid type 1. In tissue injury, the secondary inflammatory response is triggered and causes further tissue injuries. Tissue injury generates cytokines and pain mediators including bradykinin, and they activate nociceptive afferent nerves and trigger pain. The main causes of chronic pain are from extended hyperalgesia after a VOC and central sensitization. Neuropathic pain could be due to central or peripheral nerve injury, and protein kinase C might be associated with the pain. In central sensitization, neuroplasticity in the brain and the activation of glial cells may be related with the pain." (Takaoka, et al., 2021).

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 denial of the admission for three days is overturned. Uphold denial of the fourth hospital day.

The medical necessity of hospital admission for 3 days is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure, atrial fibrillation and hypertension

Treatment: personal care assistance (PCA) services 24 hours per day 7 days per week (live-in)

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

This is a patient with chronic medical problems including congestive heart failure, atrial fibrillation and hypertension. She lives alone in a private home.    She is currently approved for PCA services totaling 56 hours/week. She is requesting an increase in Personal Care Assistance (PCA) services to 24 hours per day 7 days per week (live-in), which is currently under review.  

The Uniform Assessment System (UAS) report was reviewed. The evaluation was primarily performed when she was an inpatient at the hospital.  The patient's cognition is described as "modified independence." She is fully alert and oriented. She requires maximal assistance for bathing, lower body dressing and toilet transfers/use. She is frequently incontinent of bladder and occasionally incontinent of bowel. Extensive assistance is required for personal hygiene, upper body dressing and ambulation.  

The patient's significant functional impairments support the medical necessity of Personal Care Assistance (PCA) services.  However, her condition and functional needs are not at a level or unpredictable as to require the requested Personal Care Assistance (PCA) services 24 hours per day 7 days per week (live-in). This physician would agree the patient may require 24-hour monitoring. 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 increasing the PCA services to 12 hours/day, 7 days/week (84 hours total). 

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

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested personal care assistance (PCA) services 24 hours per day, 7 days per week (live-in) is not medically necessary.  

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the patient's health and safety can be appropriately provided and maintained by increasing the PCA services to 12 hours/day, 7 days/week (84 hours total).

The insurer's denial of coverage for personal care assistance services 24 hours per day 7 days per week (live-in) is modified. Medical Necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain and Pancreatitis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is partially overturned.

The patient is an adult female with a history of alcohol abuse. She presented to the ER (emergency room) with upper abdominal pain and chest pain. There was some vomiting.
The patient was hemodynamically stable. Lipase was elevated at 297. She was admitted with a diagnosis of pancreatitis. She was hydrated and placed on IV (intravenous) PPI (proton pump inhibitor) and Zofran. By the next day her pain was noted to be improving, and she tolerated a clear liquid diet. The following day, her pain was improved, and she was noted to be tolerating a diet. She was discharged on day #3.

The Inpatient Hospital Admission was medically necessary, in part. The proposed acute inpatient hospital stay for the first day was medically necessary, and the acute inpatient hospital stay for the remainder of the hospital stay was not medically necessary. 

The patient presented with upper abdominal pain and had a lipase greater than 3 times normal. As the patient met 2 out of 3 criteria for acute pancreatitis requiring inpatient admission, the acute inpatient admission was medically necessary. By the next day, the patient's abdominal pain was noted to be improved. As she was hemodynamically stable, tolerating a clear liquid diet, and had no intractable vomiting, need for prolonged NPO (nothing by mouth), obstruction, GI (gastrointestinal) bleeding, or signs of worsening acute pancreatitis, she was medically stable for discharge. Therefore, the proposed acute inpatient hospital stay for the first day was medically necessary, and the acute inpatient hospital stay for the remainder of the hospital stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right epididymo-orchitis. 
Treatment: Full hospital admission. 
The insurer denied the full hospital admission. 
The health plan's determination is overturned in part. 

This male patient was admitted through the emergency room (ER) to urology with a worsening right epididymo-orchitis after 3 days of oral doxycycline therapy. Vitals were Temperature 99 degrees Fahrenheit, pulse 102, and blood pressure (BP) 110/56. Computed tomography (CT) imaging and Ultrasonography demonstrated marked scrotal edema with potential gas in the anterior penis. The white blood cell count (WBC) count was 15,600. The urinalysis had leukocyte esterase. Triple intravenous (IV) antibiotic therapy was administered. Infectious disease (ID) was consulted. 

An acute inpatient level of care was medically necessary for 2 days. 
Scrotal edema or infection is not manageable in observation care. Orchitis not manageable in observation care. The presence of gas in the affected tissue after 3 days of outpatient antibiotic therapy is very concerning for Fournier's gangrene. This clinical condition requires close inpatient follow-up as clinical deterioration can be rapid. By day 3, the patient was stable and no longer required an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: acute depression; bizarre delusions

Treatment: inpatient behavioral health treatment

The insurer denied coverage for 7 days. The denial was modified.

This patient is a female admitted for acute inpatient psychiatric treatment. She was diagnosed with Schizoaffective Disorder, Bipolar; Rule Out Major Depressive Disorder with Psychosis; Rule out immunodeficiency Induced Psychosis. She was discharged with the diagnosis of Schizoaffective Disorder, Bipolar Type. 
 
The insurer has denied coverage for inpatient behavioral health treatment.

The medical record indicates the patient had been residing in a nursing home facility and was experiencing the following symptoms; acute depression with crying spells, thoughts of harming herself, paranoid and bizarre delusions, internal stimulation, and odd mood and behavior. She was prescribed the following medications: Risperdal 4 mg daily and Prozac 20 mg daily at the time of admission. She had a history of extensive mental illness. She had a history of multiple psychiatric hospitalizations and multiple medication trials. She was single, unemployed and undomiciled. She had poor impulse control. She had thought disorganization. She was treated with Invega Sustenna and Risperdal.   

Based upon the information available this patient required acute inpatient psychiatric treatment; the insurer's denial is reversed for a specified date range of time. She had ongoing severe psychosis through the first 3 days. The level of this psychosis could not be safely or effectively treated outside of an acute inpatient setting. The acute inpatient hospital treatment on these dates is consistent with the general standards of medical/psychiatric care, APA Guidelines for the Treatment of Schizophrenia, and InterQual Behavioral Health Criteria 2018 Adult and Geriatric Psychiatry, Hospitalization, Psychiatric, Adult, Mental Health Criteria.  

There is no medical documentation indicating the need for acute inpatient psychiatric treatment for the last 4 days; the insurer's denial for these days is therefore upheld. This finding is consistent with the general standards of psychiatric care and the APA Guidelines for the Treatment of Patients with Schizophrenia.  

The health plan did not act reasonably with respect to the denial of inpatient treatment for one of the specified date ranges.

Based on the above, the medical necessity for the behavioral health inpatient treatment for a specified range is partially substantiated. The insurer's denial is modified. Approve one date range and deny the other date range.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic pain. 
Treatment: Outpatient Procedures (64418 x5, 64400 x5, 64405 x5, 64450 x5, 20553 x5). 

The insurer denied coverage for Outpatient Procedures (64418 x5, 64400 x5, 64405 x5, 64450 x5, 20553 x5). 

The denial is modified. 

This is a female patient with a medical history of systemic lupus erythematosus (SLE) and chronic migraine headaches. The patient has chronic pain involving her head and neck. A neurology note states the patient gets trigger point injections (TPI) every 4 weeks for this pain and she benefits from these injections. Office notes describe the plan as "TPI/B12 today" and document trigger point injections of >3 muscles (bilateral trapezius, CPS, rhomboids). Injections for suprascapular, greater and lesser occipital nerve block were also performed. A pre-injection pain rating of 6 is recorded but no post-injection pain rating is reported. 

There is some evidence supporting the benefit of TPI for headaches. As noted by Robbins et al "In a study surveying the use of PNBs [peripheral nerve blockers] and TPIs in headache treatment among American Headache Society members, 75.3% (122 practitioners) of the respondents used TPIs as part of their headache management (Table 1). The most common headache diagnoses in which TPI were performed were chronic tension-type headache (CTTH) (81.5%) and chronic migraine (CM) (67.7%)." 

Therefore TPI can be considered medically necessary for this patient and TPI charges (20553 x 5) should be approved. The health plan did not act reasonably with sound medical judgment in the denial of TPI. 

Nerve blocks were also performed. However, nerve blocks are not mentioned in the visit note, plan or the appeal letter; only TPI are mentioned. No information is provided to counter the insurer's decision to deny Nerve Block for Pain Management. Therefore, the nerve block procedures (64418 x5, 64400 x5, 64405 x5, 64450 x5) are not medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient in the denial of the nerve block procedures. 

Based on the above, the medical necessity for Outpatient Procedure (20553 x5) is substantiated, but medical necessity for (64418 x5, 64400 x5, 64405 x5, 64450 x5) is not substantiated. The insurer's denial is modified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Developmental delay, congenital heart disease

Treatment: Caregiver Family advocacy and Support service (CFASS)

The insurer denied coverage for Caregiver Family advocacy and Support service (CFASS).

The denial is modified.
 

Given the age, trisomy, developmental delay, congenital heart disease, and patient dependent on feeding tube and with nursing coverage not entirely dependable; the Caregiver Family advocacy and Support service (CFASS) coverage needs to be further expanded from 8 hours /month to 16 hours per month (4 hours per week). This will ensure that patient will have the adequate resources for care in the community. The studies have shown that CFASS and related services have been successful in decreasing healthcare utilization.

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 Caregiver Family advocacy and Support service (CFASS) coverage is medically necessary and needs to be further expanded from 8 hours /month to 16 hours per month (4 hours per week).