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

Orthopedic
Surgical Services

Diagnosis: lower extremity edema
Treatment: Lipectomy and Panniculectomy 
The insurer denied Lipectomy and Panniculectomy. The health plan's determination is overturned in part. The Lipectomy is medically necessary. The panniculectomy is not medically necessary.

This is a female with history of lower extremity lipedema. She started with symptoms after puberty which got worse after her pregnancies. She has been seen by vascular surgery with an appropriate and negative workup for venous insufficiency. She has had disproportionate heaviness in her thighs which has not changed with weight lass (despite 30 lb (pounds) weight loss recently). She also has a symptomatic abdominal pannus after her weight loss. This includes symptoms of rash under her abdomen and difficulty with personal hygiene.

The Lipectomy is medically necessary. The panniculectomy is not medically necessary.
Liposuction is medically necessary. This female has failed medical treatments, and liposuction is an effective treatment for lipedema. This patient's vascular surgeon has diagnosed her condition as lipedema, and she has failed to improve with conservative treatments. Liposuction is the treatment of choice for her condition and is medically necessary.
The panniculectomy is not medically necessary. The medical records do not provide documentation in the form of PCP (primary care provider) or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to physician directed topical therapy or 2) despite initial response, have recurred and caused significant functional impairment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genitourinary/ Kidney Disorder.
Treatment: Inpatient Hospital.
The health plan denied the inpatient hospital stay as not medically necessary. 
The health plan's determination is overturned in part. 

The patient is a male with a history of a right staghorn calculus, who underwent right percutaneous nephrolithotomy (PNCL). The patient had residual stone at the end of the case, and the plan was to return for a second look procedure. A computed tomography (CT) scan revealed residual stone, for which the patient underwent an interventional procedure  for internalization of the nephroureteral access. His hemoglobin was 11.0, down from 12.4. 
At issue is the medical necessity of the inpatient admission.
The health plan's determination is overturned in part.
The requested health service/treatment of inpatient admission was medically necessary for this patient for part of the stay. It was reasonable for the patient to stay through post-operative day 2. The patient underwent an uncomplicated percutaneous nephrolithotomy, with plans for an intervention (internalization of nephroureteral stent). The patient meets the attached Milliman Care Guidelines (MCG) Urological Procedure guideline for admission as the patient underwent two urological procedures - percutaneous nephrolithotomy, then an internalization of that access in interventional radiology. In review of the documentation, there did not appear to be an appropriate reason to board the patient the last additional day. Therefore, the inpatient admission was medically necessary through post-operative day 2.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems/Dental/Decay/Root Involvement.  
Treatment: Root Canal Therapy and Crowns. 

The health plan denied the dental treatment plan. 
The health plan's determination of medical necessity is overturned, in part. 

The patient is a female who presents with a medical history of von Willebrand's disease. RCT (root canal therapy) and crowns are being requested at this time. 
At issue is the medical necessity of the requested dental treatment plan. 

The health plan's determination of medical necessity is overturned, in part. 

There are hemostatic agents that help control bleeding tendencies in patients with von Willebrand's disease during dental procedures and surgeries; therefore, RCTs and crowns are not the only dental treatment options available for patients with bleeding tendencies. The need for RCTs and crowns is based on the prognosis of the tooth and size and location of the decay, not due to patient's bleeding disorder. 

According to the submitted radiographs, tooth #21 has fractured and is missing a large portion of tooth structure from decay. The pulpal nerve is exposed. Tooth #28 has minimal decay that is not close to the pulpal nerve. Tooth #27 had a large decay that was in close proximity to the pulpal nerve that required RCT treatment. RCT was performed on tooth #27. A tooth that has been root canal treated will require a crown to prevent the tooth from fracturing. As such, a RCT and crown for tooth #21 is medically necessary to restore the tooth to proper function. A RCT and crown for tooth #28 is not medically necessary. Tooth #28 can be restored with a filling. A crown on tooth #27 is medically necessary to protect the root canal treated tooth from fracturing.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right sided hemiplegia, developmental disorder of speech, difficulty walking, epilepsy, low vision in the right eye, microcephaly, and rosacea

Treatment: Consumer Directed Personal Assistance Services (CDPAS) 54.5 hours per week, current procedural terminology (CPT) code T1019

The insurer denied coverage for CDPAS 54.5 hours per week, CPT code T1019

The denial is modified

This is a patient with right hemiplegia, microcephaly, and epilepsy. She lives with her parents and brother in a private home. She attends a social day care program 6 hours/day (5 days/week). The most recent nursing assessment indicates that the patient's needs can be met with 22.75 hours of CDPAS per week. The patient is requesting a resumption of CDPAS 54.5 hours per week, CPT code T1019.  

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as severely impaired. However, she is "alert to person, place and situation." The patient requires maximal assistance for bathing, personal hygiene, and dressing. She is independent with toilet transfers/use. She is frequently incontinent of bladder and continent of bowel. According to the provider note, the patient "is able to walk independently." Her seizures were described as "not intractable, without status epilepticus, Hierarchical condition category (HCC)-chronic/persistent but manageable with current medications on board per neurology." According to the neurology physician assistance (PA) office visit note, the patient's "Epilepsy has been stable. She continues to have 4-6 seizures per month. Many of these seizures are short in length and last for less than 2 minutes." It was also noted "She doesn't fall over with her seizures. She doesn't lose bowel or bladder function or bite her tongue."  

The patient's limited cognitive deficits and significant functional impairments support the medical necessity of CDPAS. However, her condition and functional needs are not at a level or unpredictable as to require the requested CDPAS 54.5 hours per week; particularly with the social day care program 6 hours/day (5 days/week). This physician notes that an additional 12 hours (6 hours/day for 2 days) combined with the currently approved 22.75 hours of CDPAS per week for a total of 34.75 CDPAS hours/week, is medically necessary, allowing the patient the ability to continue living safely at home with her family.  

From a physical medicine and rehabilitation perspective, CDPAS 54.5 hours per week, is not considered medically necessary for this patient.  

An additional 12 hours (6 hours/day for 2 days) combined with the currently approved 22.75 hours of CDPAS per week for a total of 34.75 CDPAS hours/week, is medically necessary.

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

The insurer's denial of coverage for Consumer Directed Personal Assistance Services (CDPAS) 54.5 hours per week, current procedural terminology (CPT) code T1019 is modified. Medical Necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Detoxification
 
Treatment: Inpatient hospitalization for Alcohol Detoxification
The insurer denied the Inpatient hospitalization for substance detoxification treatment. The denial was modified.
This patient is a male was admitted to inpatient substance detoxification treatment in late 2018 for alcohol detoxification. He had withdrawal symptoms including sweats, tremors, joint pain, abdominal pain, sleeping problems, agitation, headache, teary eyes, and anxiety and had a CIWA of 10. He reportedly had at least 10 past treatment episodes including multiple past inpatient substance rehabilitation treatments and detoxification treatments. He also had depression and anxiety and had past psychiatric hospitalizations. He reportedly had medical issues including gastroesophageal reflux and asthma. He took Librium as a detoxification medication. He was stepped down to inpatient substance rehabilitation treatment in the later part of this admission.
The insurer denied coverage for inpatient substance detoxification treatment in the earlier part of this admission as not medically necessary treatment. They stated that he was not at risk of severe withdrawal and did not require 24 hour inpatient detoxification treatment then in the hospital and they recommended a less restrictive level of care. 
This reviewer disagrees with the decision to deny coverage during this time but agrees with the denial of days on the later days of admission. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that patient with life threatening or complicated withdrawal such as delirium tremens or withdrawal seizures are in need of inpatient substance detoxification. It also states that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  It also reports that patients using large amounts of alcohol are at a higher risk of having delirium tremens after cessation of use. 
This patient required the treatment received in this hospital for medical detoxification treatment during the earlier part of this admission. He was using large amounts of alcohol daily and was considered at high risk for life threatening withdrawal including delirium tremens. He also was using cannabis. He had a history of depressive symptoms and multiple past psychiatric hospitalizations. 
Based on the above, the denial of inpatient hospital services at the withdrawal and stabilization services level of care is modified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder, Severe Intellectual Disability
 
Treatment: Increase of personal care aide services

The insurer denied increased personal care aide services. The denial was modified.

This male patient had developmental delays in social communication and interaction, ritualistic and perseverative behaviors, and a history of physically aggressive, self- injurious, impulsive, and assaultive behavior, as well as property destruction and past elopement attempts. He had diagnoses of Autism Spectrum Disorder, Severe Intellectual Disability, Intermittent Explosive Disorder, and Disruptive Mood Dysregulation Disorder. He lived with his mother who took care of him. This patient required assistance with ADLs as he was unable to perform most ADLs except with assistance, and was unable to perform household tasks; therefore, he required personal care services. 

The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Autism and Other Pervasive Developmental Disorders reports that some patients with autism and developmental delays have severe deficits in adaptive functioning and require assistance for activities of daily living, as well as supervision for safety and for structure as they often require intense sustained structure due to their delays. It appeared that his mother was not able to provide 24 hours per day supervision and 15 hours per week was not enough supervision for this patient with severe deficits in development, inability to care for his basic needs, and his history of aggression and self- injurious behavior. This placed others in danger; therefore, he required at least 8 hours per day of supervision and consumer directed personal care aide services. If he were to need 24 hour supervision, then he would be a candidate for a therapeutic residential treatment which could provide this treatment. 

Based on the above, the insurer's denial of consumer directed personal care aide services (CDPAS) 168 hours per week (24 hours per day, 7 days per week) is modified. Deny 168 hours per week (24 hours per day, 7 days per week). Approve 56 hours per week (8 hours per day, 7 days per week).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: bilateral quad tendon ruptures 
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned in part. An 11-day stay was medically necessary. 

This patient is a man who, one day prior to admission, fell down a flight of stairs. He presented to an outside hospital and then was transferred to the treating facility for bilateral quadriceps tendon ruptures. The patient underwent primary open repair of bilateral quadriceps tendon ruptures; surgery was without complication, and the patient was placed in bilateral cylinder casts postoperatively.

The acute inpatient admission was medically necessary for 11 days. This is a morbidly obese patient (350+ lbs., body mass index (BMI)>40) with bilateral lower extremity injuries that prohibit safe ambulation. Rupture of BILATERAL quadriceps tendons in a medically complex patient is a very different clinical situation than a single tendon. It is a very rare injury, and with minimal trauma (falling downstairs,) the most common patient would be one with multiple medical comorbidities, such as this patient with morbid obesity, obstructive sleep apnea, hypertension, asthma, and stage 3 chronic kidney disease. Preoperative steroid use, which this patient had, according to the medical record, is also a risk factor for this rare injury. Postoperatively, it is not surprising that a 350+ lb patient wearing bilateral cylinder casts would have difficulty with safe, independent ambulation and activities of self-care and daily living.
Appeal type: Medical necessity
Decision: Overturned

This patient is under consideration for bariatric surgery. On 4/19/19, the patient was 67 inches tall and weighed 226 lbs. This corresponds to a body mass index (BMI) of 35.4 kg/m2. On 11/20/18, the weight was 232.8 lbs (BMI 36.5 kg/m2). The patient has comorbid health conditions of hyperlipidemia, gastroesophageal reflux disease (GERD), and non-alcoholic fatty liver disease/steatohepatitis (NASH). Bariatric surgery and the corresponding inpatient admission is under review. 

The health plan's determination is overturned in part. Given this patient's diagnosis, her current health condition and the evidence based literature, the proposed sleeve gastrectomy procedure is medically necessary for this patient. Inpatient admission is also medically necessary and is consistent with the standard of care.
However, the pyloroplasty (CPT 43659) is not medically necessary as this procedure is not supported by evidence based literature within the bariatric surgical community as a standard of care intervention to minimize the risk of staple line leak.Sleeve gastrectomy is in accordance with generally accepted standards of medical practice, is clinically appropriate and considered effective for the member's disease, is not cosmetic or experimental, is proven to be more medically effective than any standard nonsurgical care and treatment, and is not for the convenience of the member or physician. The proposed sleeve gastrectomy is medically necessary for this patient and is consistent with the standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sjogren's syndrome with pulmonary fibrosis
Treatment: Personal Care Aide (PCA): 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: 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 overturned in part.

This patient is of advanced age and has Sjogren's syndrome with pulmonary fibrosis and requires portable home oxygen. She lives alone in a second-floor walk-up, 2-bedroom apartment. She is approved for 6 hours per day, 7 days per week for a total of 42 hours day. Under review is the requested increase PCA: 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 Uniform Assessment System (UAS) report was reviewed. The patient's decision-making ability is described as "modified independent." She is fully oriented and alert. She requires extensive assistance for personal hygiene. Maximal assistance is required for bathing, dressing, and toilet transfer/use. She is occasionally incontinent of bladder and continent of bowel. She requires maximal assistance for ambulation. Her cognitive status, ability to use a Personal Emergency Response System (PERS), as well as "verbalize a plan of action in case of an emergency" do not support the requested increase PCA: 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. However, her progressive pulmonary fibrosis, requiring daily home oxygen, weakness and functional decline support an increase PCA to 12 hours/day, 7 days/week totaling 84 hours; allowing the patient the ability to continue living safely at home.
  
The insurer's denial of coverage for personal care aide (PCA): 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 modified as noted above. Medical necessity is not substantiated for 12 hour per day 7 days a week (split shifts) for total of 168 hours weekly. However, 12 hours per day 7 days a week for a total of 84 hours weekly is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

The patient is a male with a significant past medical history for diabetes mellitus, hypertension, chronic kidney disease, gastroesophageal reflux disease and nephrolithiasis. The subject under review is for the medical necessity of increase in personal-care service hours from 17 hours a week to 40 hours a week. The patient has currently been approved for 17 hours a week. The patient requests additional services to 40 hours a week. The health plan's determination is overturned, in part. The requested health service/treatment of Consumer directed personal cares assistance services increase from 17 to 40 hours per week is not medically necessary for this patient. However, an increase to 20 hours a week is medically necessary.
The patient's son stated that the patient needs assistance with feeding, medication, and walking. He reports the current hours are not enough, and are not adequate for bathing, dressing, toileting, and housekeeping related services. Per the Uniform Assessment System - New York Comprehensive Community Assessment Report, the patient is independent with eating, ambulates in his own home with an assistive device, and is continent of bowel and bladder. The Uniform Assessment System - New York Comprehensive Community Assessment Report recommended a total of 19 hours a week for personal care services. Based upon review of the records provided along with the documents provided in regards to nursing and aid hours, the patient would need additional hours to support basic functions such as activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The recommended increase in the personal-care hours from 17 hours a week to 20 hours a week should be sufficient to maintain activities that were noted to be medically necessary according to the documentation provided. There is no medical need for additional hours other than 20 hours a week.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain
Treatment: inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is modified. 

This is a patient with chronic medical problems including hypertension, kidney disease, kidney stones, and chronic obstructive pulmonary disease. He presented to the emergency department (ED) with worsening back pain and the inability to walk. The patient was admitted to inpatient services due to the inability to ambulate and for the (empiric) treatment of L (lumbar) 4-5 discitis. Treatment included intravenous antibiotics and pain management. During the hospital stay, the patient was seen by Neurosurgery, Oncology, Infectious Disease, Physical Medicine & Rehab, physical therapy (PT) and occupational therapy (OT). Under review is the medical necessity of inpatient hospital admission.

The enclosed clinical information does not support a level of medical acuity or complexity that supports acute inpatient hospitalization for the total length of stay. After approximately 48 hours of observational care, the patient was appropriately admitted to the acute care hospital; particularly due to severe back pain, increased blood pressure (175/83) and laboratory inflammatory markers.  However, he was seen by orthopedic and neurosurgical teams; both of whom did not recommend surgical intervention. A CT (computed tomography) guided L4-5 biopsy was negative via microbiology and pathology studies. He was placed on IV (intravenous) antibiotics (empirically) via the Infectious Disease physician.  Ongoing clinical workup including physical examination, radiologic studies and laboratory blood studies failed to demonstrate evidence of significant acute or recurrent pathology that supported acute inpatient hospitalization. In addition, there were no specific "red flag" symptoms such as bowel/bladder (cauda equina) symptoms, saddle anesthesia or focal motor weakness. Vital signs were stable and there was no fever. Continuing treatment could have been safely provided at a lower level of care.  According to the case management notes, referrals had been made to lower level of care (i.e. acute and subacute rehabilitation) and the patient could have been safely discharged.

From a physical Medicine and rehabilitation/pain Management perspective, as well as within a reasonable degree of medical certainty, inpatient hospital admission for the entire duration of the stay was not medically necessary for this patient.  

From a physical Medicine and rehabilitation/pain Management perspective, as well as within a reasonable degree of medical certainty, the inpatient hospital admission was medically necessary for a partial duration of the total hospital stay for this patient. 

The insurer's denial of coverage for the inpatient hospital admission is modified. Medical Necessity is partially substantiated.