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

Diagnosis: Orthopedic/Musculoskeletal-debility.
Treatment: Home Health Care. 
The insurer denied an increase in personal care hours to 84 hours per week. 
The denial was overturned, in part. 

The patient is a male with a past medical history significant for prostate cancer, gait abnormality, eosinophilia, left bundle branch block and pancytopenia. He currently lives alone in an apartment. He is non-ambulatory and moves around in the apartment in his wheelchair. The patient is currently approved for 6 hours a day 7 days a week for a total of 42 hours per week. The patient's provider requested an increase in personal care level services to 7 days a week 12 hours a day for a total of 84 hours a week.
The patient's health plan denied additional services stating the patient is receiving care hours for basically all his activities of daily living. The tasking tool notes that the patient needs a total of 33.42 hours of care week and the patient is currently receiving 42 hours a week.
At issue is the medical necessity of home care/personal home health care (HHC)-Level 2 personal care services, per 15 minutes increase to 84 hours per week.
The health plan's determination of medical necessity is overturned, in part.
The requested health service is medically necessary for this patient, in part.
This reviewer recommends overturning the decision in part. An increase in personal care service hours to 56 hours a week is medically necessary for this patient. Additional service hours are necessary for the patient's unscheduled needs.
The patient is a male with multiple medical problems. He suffers from age-related debility, dementia, and prostate cancer. He did have heart block which was corrected with pacemaker placement. The patient currently lives alone in an apartment. He is non-ambulatory and moves in the apartment in his wheelchair. He currently is receiving 42 hours per week and is requesting 84 hours. The patient has incontinence and has been managed with pull ups. The comprehensive nursing assessments were reviewed, with the last assessment, noting no change in his status since the last encounter.
The patient does have unscheduled needs which are not being met completely with the hours provided. 56 hours per week is medically necessary for this patient.  Splitting these hours may be more appropriate to meet this patient's needs. 84 hours per week is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: heart disease, hypertension and venous stasis ulcers

Treatment: personal care aide (PCA) level 2 - live-in per diem - 7 days per week

The insurer denied coverage for personal care aide (PCA) level 2 - live-in per diem - 7 days per week

The denial is modified 

This is an elderly female with diagnoses that include heart disease, hypertension and venous stasis ulcers.  She lives alone in a 1-bedroom apartment.  The insurer approved personal care aide (PCA) level 2: 5.5 hours/day - 7 days/week (38.5 hours/week) and the request is for personal care aide (PCA) level 2: live-in per diem 7 days/week.

On the Uniform Assessment System (UAS) report the patient's cognition is described as modified independent.  She reports requiring maximal assistance to total dependence for much of her Instrumental Activities of Daily Living (IADL) tasks including ordinary housework, meal preparation and shopping.  She reportedly requires extensive assistance for bathing, lower body dressing and toilet use.  Limited assistance is reportedly needed for upper body dressing, bed mobility, locomotion, toilet transfer and ambulation. She reports being independent for personal hygiene and eating.  The patient is reportedly frequently incontinent of bladder and continent of bowel.  

The patient's activities of daily living (ADL) status and self-sufficiency have declined over the prior 90 days.  The patient's condition and functional deficits are not at a level or unpredictable as to require the requested personal care aide (PCA) level 2: live-in per diem 7 days/week.  This physician would agree that the patient may benefit from monitoring for safety, particularly due to her progress weakness and balance deficits.  However, personal care services (PCS) for companion care or safety supervision without the direct provision of task assistance is not a covered service.  However, the approved personal care aide (PCA) 5.5 hours/day is insufficient, given her progressive clinical and functional deficits.  Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained by increasing personal care aide (PCA) to 10 hours/day, 7 days/week.    

From a physical medicine and rehabilitation perspective, the requested personal care aide (PCA) level 2: live live-in per diem 7 days per week is not medically necessary.  However, personal care aide (PCA) level 2; 10 hours/day, 7 days/week (70 hours total) 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 - live-in per diem - 7 days per week services is not substantiated. However, personal care aide (PCA) level 2; 10 hours/day, 7 days/week (70 hours total) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Trauma
Inpatient hospital

Diagnosis: Traumatic brain injury and a left ventriculoperitoneal shunt.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is overturned in part. 

The patient is a female with a history of traumatic brain injury and a left ventriculoperitoneal shunt who had undergone a wound revision with mesh cranioplasty performed by the plastic surgery team. Subsequently, a baclofen trial was conducted with neurosurgery service. She presented to the hospital with a right-sided scalp wound associated with delayed healing. Specifically, the suture line from the previous plastic surgery closure performed was affected.

Two of the days in question were medically necessary at the inpatient level of care. During this time period, this patient remained severely confused and oriented only times one. It was reported that the patient had increased sleepiness and was unable to answer simple questions. The patient was not withdrawing to noxious stimuli. The patient was still receiving intravenous antibiotics per infectious disease service recommendations. The plastic surgery team was still monitoring closely the scalp flap. Due to the complexity of care during this period of time, an acute inpatient level of care was indicated.

For the remainder of the stay, this patient remained in relatively stable clinical condition. This patient remained afebrile and hemodynamically stable and was not undergoing any kind of treatment that would require admission at the acute inpatient level of care. The patient was able to open her eyes spontaneously and was able to track objects. During this period of time, the patient was waiting for a craniotomy. Based on the clinical condition, a lower level of care was most appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient is a male with a history of nonvalvular atrial fibrillation, liver cirrhosis, and esophageal varices. He is currently on Xarelto. Transcatheter closure of the left atrial appendage and inpatient admission are under review. The health plan's determination is overturned in part. Left atrial appendage closure in the setting of this case is more beneficial than any standard treatment options as the only alternative is anticoagulation which is contraindicated in this case. Left atrial appendage closure can be accomplished in the outpatient setting, compared to an inpatient admission, without an increased risk of complications. An inpatient admission for left atrial appendage closure has not been established as standard of care towards improved procedural outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Cardiac/Circulatory Problems
Surgical Services  (All)

Diagnosis: Varicose Veins
Treatment: Stab Phlebectomy and Sclerotherapy with Ligation 
The insurer denied the Stab Phlebectomy and Sclerotherapy with Ligation.
The health plan's determination is overturned in part. 

Left leg ambulatory phlebectomy with ligation is medically necessary for this patient based on the peer reviewed literature.
Left leg vein sclerotherapy is not medically necessary for this patient

The patient is a female who presents with bilateral lower extremity symptomatic varicose veins. Her main complaints include pain and swelling. She has attempted and failed conservative therapy with graded compression stockings without symptomatic relief for the past six years. She works as a nurse anesthetist and is required to be on her feet for long periods. Her pain interferes with her work activities. Her duplex ultrasound demonstrates reflux at the saphenofemoral junction only but not in the great saphenous vein.

-Left leg ambulatory phlebectomy with ligation is medically necessary for this patient based on the peer reviewed literature.
-Left leg vein sclerotherapy is not medically necessary for this patient.
Stab phlebectomy is a well-established and current treatment for symptomatic varicose vein tributary veins. The most recent consensus guidelines for the Society for Vascular Surgery and the American Venous Forum support stab phlebectomy for the treatment of symptomatic varicose veins when the patient's saphenous vein reflux has been treated either in staged or concomitant fashion. There are several current peer reviewed studies which support the use of concomitant stab phlebectomy in patients being treated with thermal ablation for symptomatic varicose veins. The ligation is medically necessary in conjunction with the stab phlebectomies to decrease the risk of bleeding from large feeding varicosities or perforators.
These procedures are supported by the most recent consensus guidelines from the Society for Vascular Surgery and the American Venous Forum. They are considered standard of care procedures in the Vascular Surgery Community and are Medically Necessary for this patient.
Based on the records provided, left vein sclerotherapy is not being requested. Therefore, it is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Age-related cognitive decline, anxiety, chronic atrial fibrillation, hypertension, hallucinations, and polyarthritis
Treatment: personal care aide 7 days x 12 hours, total 84 hours per week
The insurer denied coverage for personal care aide 7 days x 12 hours, total 84 hours per week
The denial is modified.

This is an elderly patient with medical problems including atrial fibrillation, hypertension and arthritis. She lives alone and her daughter lives on the second floor of the house. The insurer approved a personal care aide (PCA) 35 hours/week, and the request is for 84 hours/week.

According to the Uniform Assessment System (UAS) report the patient's cognition is described as minimally impaired. She is totally dependent to maximal assistance for Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She requires extensive assistance for bathing and dressing. Only limited assistance is needed for toilet use. She is frequently incontinent of bladder and occasionally incontinent of bowel. The patient is otherwise independent for personal hygiene, eating, bed mobility, locomotion, toilet transfer and ambulation (with a cane). There have been no reported falls over the prior 90 days. The patient's clinical and functional deficits are not at a level and unpredictable as to require the requested PCA 84 hours/week. Increasing a PCA to 56 hours/week is reasonable given her impairments. This physician would also agree that given the patient reported cognitive decline and propensity for wandering in the home, she may require additional 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 records reviewed, the patient's health, safety and reasonably high functional ability can be appropriately provided and maintained by increasing PCA to 56 hours/week.  

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 7 days x 12 hours, total 84 hours per week is not substantiated. However, 56 hours/week are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis. 
Treatment: Adbry. 

The insurer denied coverage for Adbry. 

The denial is Modified. 

The patient is a diabetic adult with a diagnosis of atopic dermatitis.  The condition is exacerbated by prurigo nodularis.  The patient has been treated with Dupixent and topical therapy with Opzelura and topical steroids.  The request is for Adbry with continuation of topical Opzelura and discontinuation of Dupixent.  

The patient has atopic dermatitis with prurigo nodularis.  Dupixent is Food and Drug Administration (FDA) approved for both conditions.  It is unclear from the provided documentation the exact length of treatment with Dupixent.  In light of the lack of appropriate clearance of the atopic dermatitis, the use of Adbry would be a reasonable next management step with discontinuation of Dupixent.  The simultaneous use of Adbry and Dupixent would not be within the medical standard. Topical therapies, steroids or Opzelura, may be required for breakthrough atopic lesions while on Adbry but this cannot be determined until the patient has had an adequate trial of Adbry monotherapy.  

Thus, the use of Adbry monotherapy is approved with the documentation of failed therapy with Dupixent.   Should Adbry inappropriately control the patient's symptoms, and with appropriate documentation of failure of topical steroids and tacrolimus or pimecrolimus to treat residual flares, the use of Opzelura topical may be and alternative topical adjuvant.  It is within the standard of care for the patient to treat with Adbry monotherapy and use topical steroids for any breakthrough flares, should they occur.  

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

The insurer's denial of coverage for the Adbry is modified. Medical Necessity is substantiated for the patient to treat with Adbry monotherapy and use topical steroids for any breakthrough flares, should they occur.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal-Other-Gastroenteritis
Treatment: Inpatient hospital stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has overturned in part the health plan's determination.

At the time of his admission, the patient was a previously healthy toddler, brought by his parents to the emergency department (ED) with vomiting and diarrhea since the morning. At triage, the patient was noted to be alert and active and drinking from a bottle. He was afebrile with normal vital signs. The ED physician notes state the patient had about 15 episodes of non-bloody, non-bilious vomit and 6 episodes of non-bloody diarrhea. The ED physician documented that he was active, in no distress, non-toxic, well hydrated, well appearing, attentive and interactive and appropriate for age, smiling and playful, crying tears when upset but quickly consolable. The exam was normal. Electrolytes showed bicarbonate (bicarb) of 13 and potassium of 5.1 with a notation that it was a hemolyzed specimen. He was given Zofran, a 20 milliliter(ml) /kilogram( kg) normal saline bolus, then started on an infusion of Dextrose(D)5% and 1/2 normal saline(NS). He was admitted to the pediatric ward late in the evening for gastroenteritis, continued on intravenous (IV) fluid and oral fluid (no vomiting), and discharged. He continued to have diarrhea during the hospitalization, but was otherwise well. Follow up electrolytes showed a potassium of 2.6 and bicarb of 16 without a comment about specimen hemolysis. He was given supplemental IV potassium to correct the hypokalemia and later the potassium was 3.5 and bicarb 15 without comment about specimen hemolysis.  The physician notes explained the low bicarb and potassium as being due to diarrheal losses. 
The inpatient stay was medically necessary for this patient, in part.
Although the notes all indicate the baby did not appear clinically dehydrated, the laboratory values suggested a mild to moderate dehydration based on the low bicarbonate level. The morning after admission, the potassium was 2.6 and required correction for a safe discharge. The follow up potassium of 3.5 later in the evening showed the baby was heading in the right direction, and the baby could have been safely treated at a lower level of care at this point. So, the first night was medically necessary due to the electrolyte abnormality not able to be corrected with IV fluid in the observation/ED setting; the second night was not medically necessary because the electrolyte abnormality was corrected.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast Cancer
Treatment: Radiation Therapy for Breast Cancer - Initial Phase: 28 fractions Intensity Modulated Radiation Therapy (IMRT); Boost Phase: 8 Fractions Intensity Modulated Radiation Therapy (IMRT)
The insurer denied: Radiation Therapy for Breast Cancer - Initial 
Phase: 28 fractions Intensity Modulated Radiation Therapy (IMRT); Boost Phase: 8 Fractions Intensity Modulated Radiation Therapy (IMRT)
The denial is partially overturned

The patient is an adult female with a diagnosis of stage cT2N1M0 right breast cancer status post neoadjuvant chemotherapy and right mastectomy. Adjuvant radiation therapy was recommended, and intensity modulated radiation therapy (IMRT) was requested for both the initial chest wall radiation phase as well as the scar boost phase.

The requested intensity modulated radiation therapy (IMRT) for the initial phase is medically necessary. However, intensity modulated radiation therapy for the boost phase is not considered medically necessary.

Intensity modulated radiation therapy for the initial treatment phase would be a superior technique compared to conventional conformal radiation therapy in reducing dose to the normal 
tissues such as the skin, heart and the lung. This patient had a mastectomy done and the treatment fields are very extensive, including axillary, supraclavicular and internal mammary nodal chains, and care must be taken to minimize radiation exposure to the heart, lung and opposite breast using intensity modulated radiation therapy. In a 2007 Model Policy for intensity modulated radiation therapy, the American Society for Therapeutic Radiation and Oncology (ASTRO) considers intensity modulated radiation therapy a treatment option for "Selected cases of breast cancer with close proximity to critical structures". While intensity modulated radiation therapy is not a recommended treatment for all breast patients, for this patient, it is a medically necessary treatment and should be implemented in order to reduce the risk of treatment related toxicity.
In regard to the boost phase of radiation, the target is the mastectomy scar. The standard of care of a scar boost is with electrons. In fact, intensity modulated radiation therapy may result in more dose exposure to the lung compared to electrons. The requested intensity modulated radiation therapy for the scar boost (eight fractions), therefore, is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizophrenia
Treatment: Inpatient Mental Health Treatment

Summary: This patient was admitted to this inpatient mental health treatment in this hospital on due to psychotic symptoms including paranoid and Cotard delusions as he reportedly thought people were trying to kill him, and he thought he died and came back to life. He thought he was Jesus, did not feel safe, lacked insight, and was non-compliant with treatment .The patient had a reported diagnosis of Schizophrenia and reportedly had past psychiatric hospitalizations. He had treatment over objection for medication for Haldol and Risperidone. 

The insurer has denied coverage for the continued inpatient mental health treatment as not medically necessary. The denial was modified.
 
The American Psychiatric Association 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. The denial was partially approved because the patient reportedly still had psychotic symptoms during the denial period including paranoid delusional thinking. Notes reported that he had treatment over objection for medication for Haldol and Risperidone as he had paranoid delusions and thought people were trying to kill him. He had multiple changes in his Haldol dosage to better target psychotic symptoms. Notes reported that he had delusions though less. It also reported that he was still resistive to taking medication but took it with encouragement from this hospital staff so he still required this 24 hour hospital treatment as he likely would have been non-compliant again and decompensated more if not in this hospital setting. Notes reported that he had delusions still and did not want to take some medication so he still needed hospital treatment until then. The subsequent days of the admission were denied because there were no further reports of delusional thinking or non-compliance, and he had no reported hallucinations, disorganized thinking or behavior, or psychotic symptoms. There were also no reports of severe agitation, severe depression, and there were no reports of suicidal or homicidal ideation. Notes reported that he had no delusions, no hallucinations, had linear thought process, normal speech, was co-operative, had neutral mood, and had no acute events. Notes reported that he was participating in group and providing insight. Notes reported that he had no delusions anymore and had improved affect.