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

Diagnosis: Dizziness and diarrhea
Issue under review: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned, in part. 

This patient is a male with type 1 diabetes complicated by retinopathy, hypertension, heart failure, gastritis, and pancreatitis presented with diarrhea and dizziness. Temp 37.3, heart rate 99, blood pressure 125/77. Left 3rd finger with dark discoloration, swelling, and foul smell. He was still dizzy in the emergency department after 1 liter of normal saline and unable to get up and walk. He was treated with Zosyn and vancomycin for suspicion for cellulitis of his left 3rd finger. 

Yes, the inpatient admission was medically necessary, in part. 

This patient was admitted with dehydration, orthostatic hypotension, and finger cellulitis. Given his ongoing diarrhea and orthostasis despite intravenous hydration, he required inpatient admission. He also had cellulitis of his finger with initial concern for gangrene requiring intravenous antibiotics and assessment by orthopedics and dermatology. 

He was noted to have significant improvement in his diarrhea. He was determined to have resolving cellulitis with the appearance in part be due to trauma. He was afebrile and his blood cultures were negative. The documentation does not support that he required ongoing intravenous antibiotics or if it was determined that he should receive long-term intravenous antibiotics that these could not be administered at a rehabilitation center. His glucose levels were adequately controlled with subcutaneous insulin. He had ongoing orthostatic hypotension, which was a chronic issue in the setting of autonomic neuropathy and was not an indication for ongoing inpatient admission. Therefore, the requested inpatient admission was medically necessary, in part.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental issues
Treatment: Apicoectomy on tooth #21, retrograde filling on teeth #s 21 and 22, and anesthesia 

The proposed apicoectomy on tooth #21 and retrograde filling on teeth #s 21 and 22 are medically necessary; however, the anesthesia services are not.

The case is an appeal request for surgical endodontic therapy (apicoectomy) and retrograde filling of the apex, in two teeth - #'s21 and 22, for an adult dental patient. The teeth have had previous conventional endodontic therapy, and are restored with crowns. There is radiographic evidence of peri-apical pathology / peri-apical periodontal bone resorption indicative of chronic inflammation, leakage or tissue necrosis requiring treatment. The requested surgical treatment is reasonable and indicated.  In this case, the two teeth have shown prior therapy, are not amenable to conventional retreatment endodontic therapy, and are restored with crowns. The requested treatment meets and substantiates standard of care, and approval is recommended. 

However, there is no material submitted to substantiate any medical necessity for requested IV anesthesia services (ie, anxiety, medical management issues, complex surgery), and so these services are denied.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Sclerosis. 
Treatment: Consumer directed personal assistance services (CDPAS) 56 hours per week. 
The insurer denied coverage for CDPAS 56 hours per week. 
 The denial is modified. 

This patient is an adult with a diagnosis of multiple sclerosis. She lives alone in a 2-bedroom apartment. She is currently approved by the insurer for CDPAS 31.5 hours/week and is requesting an increase to 56 hours/week. 

According to the most recent Uniform Assessment System (UAS) report, the patient cognitive skills are described as "modified independent." She requires extensive assistance for bathing and lower body dressing. Limited assistance is needed for upper body dressing and toilet use. She only requires supervision for bed mobility, ambulation, and toilet transfer. The patient is infrequently incontinent of bladder and continent of bowel. She is independent with personal hygiene and bed mobility. She is "able to warm foods in the microwave and get drinks from the refrigerator" and "make a simple meal." She uses a walker for ambulation and taken by her caregivers to go shopping. The patient's functional status has declined compared to the UAS report from the prior year; particularly for lower body dressing and mobility (transfers/ambulation). However, the decline has been modest, and her functional ability does not support the medical necessity of increasing CDPAS to 56 hours/week. A modest increase in CDPAS is warranted. Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by increasing CDPAS to 42 hours/week. 

From a physical medicine and rehabilitation perspective, the requested increase CDPAS 56 hours per week is not medically necessary. However, increasing CDPAS to 42 hours/week is medically necessary.  

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

The insurer's denial of coverage for the consumer directed personal assistance services (CDPAS) 56 hours per week is modified. Medical necessity is substantiated for CDPAS of 42 hours/week.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Leg pain. 
Treatment: Pain injections (outpatient procedures - 27096 x1 
[sacroiliac joint injection], 20553 x1 [trigger point injection]). 

The insurer denied: Pain injections (outpatient procedures - 27096 x1 [sacroiliac joint injection], 20553 x1 [trigger point injection]). 

The denial is partially overturned. 

The patient is an adult female. The patient complains of pain in the leg with paresthesia. The patient reports pain worsening with activity and describes numbness and pain in the legs. The patient describes an electrical sensation in the sacrum and numbness that shoots down the buttocks, lateral aspect of the thigh, down to the calf and into the foot. The patient had completed three weeks of physical therapy with transition to home exercise program. The patient has a six-month history of tailbone pain. The patient had a prior L5-S1 laminectomy. Her baseline pain is eight out of ten (8/10). Exam revealed limited range of motion of the lumbar spine. Kemps test was negative. Sacroiliac joint was positive for distraction test, thigh thrust test, compression test, FABER test and Fortin finger test bilateral. X-ray of the sacrum shows moderate degenerative changes along the bilateral sacroiliac joints and symphysis pubis. 

The proposed sacroiliac joint injection is medically necessary. However, the proposed trigger point injection is not medically necessary. 

The health plan denied the injections stating that "continuation of injections beyond 12 months is not covered by your health plan." However, the literature does not support this statement; there are no specific guidelines stating that you cannot have injections more than 12 months apart. 

In regard to the trigger point injections for the sacroiliac joint, the request is not considered medically necessary in this case. There was no documentation of severe acute spasms or reproducible symptoms for the procedure. Additionally trigger point injections are still considered unproven. Furthermore, there have not been studies to support injections to be performed at the same time. 

In regard to the sacroiliac joint (SIJ) injections, the request is considered medically necessary in this case. The patient has tried and failed prior conservative treatments and continues to have positive findings on exam and on imaging. As such, the request is considered medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

The patient is a morbidly obese woman with a history of hypertension, diabetes, hyperlipidemia and coronary artery disease.  She presented to the emergency department complaining of dyspnea, chest pain and orthopnea.  Her blood pressure was 247/149 millimeters of mercury (mmHg) with a heart rate of 104 beats/minute.  Her respiratory rate was 24/minute with a room air oxygen saturation.  On physical exam her breathing was labored with use of accessory muscles of respiration.  She had bilateral pulmonary rales and peripheral edema.  She was treated with bi-level positive airway pressure (BiPAP), nitroglycerin and intravenous furosemide.  She was admitted to the hospital for management of uncontrolled hypertension and decompensated heart failure.  An echocardiogram showed normal left ventricular systolic function and moderate diastolic dysfunction.  Cardiac catheterization was planned but postponed when the patient's blood pressure remained severely elevated.  The following day the patient was in no distress.  Her blood pressure ranged from 171-177/69-86 mmHg.  Her antihypertensive medication regimen was adjusted.  The patient had no complaints.  Her blood pressure was 158/72 mmHg.  Cardiac catheterization was performed.  This showed normal left anterior descending and left circumflex arteries.  There was a patent stent in the right coronary artery.  The patient was discharged.  Medical necessity for an inpatient admission is at issue. 

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

This patient presented with acute decompensated heart failure and uncontrolled hypertension.  She was tachypneic and hypoxic and required BiPAP for ventilatory support.  She was at high risk for acute respiratory decompensation and required careful monitoring at a level that could only be provided with an inpatient level of care.  However, by the second day the patient's blood pressure, while still elevated, was improved, as was her respiratory status.  Based on the records provided, there was no medical reason why the cardiac catheterization that had been postponed on the first day could not have been performed the following day, with subsequent discharge from the hospital. 

Thus, inpatient admission was medically necessary in part.  From the information provided, it appears as if the delay in performing the cardiac catheterization was due to scheduling issues over the weekend.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal/Back Pain/Spinal Stenosis, Lumbar Region with Neurogenic Claudication; Low Back Pain
Treatment: Inpatient Hospital Admission
The health plan denied the requested inpatient stay as not medically necessary. The health plan's determination is partially overturned.

This patient with low back and leg pain underwent a (lumbar) L4-5 TLIF (transforamal lumbar interbody fusion) without complications. The patient is a female presenting with low back pain and radiculopathy due to the left 4-5-disc herniation. She obtained imaging and medical clearance as well as oral steroids and was taken to surgery.
At issue is the medical necessity for the inpatient stay.

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

The health plan acted appropriately. Per Milliman Care Guidelines (MCG) Lumbar Fusion, 2 post operative days are allowable after lumbar fusion, which is the standard.
Post operatively, the patient remained neurologically and hemodynamically stable, no infection or active bleeding was noted, no drips were noted, her pain was under control medically, and no further surgery was necessary.
In this case, there was no need for the inpatient stay from the date of admission to the surgical date, as the patient could have presented on the day of surgery for elective outpatient surgery with 2 post operative days as inpatient stay, followed by discharge. Therefore, only 2 days are allowable for inpatient stay, without any further inpatient care needs noted.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pulmonary hypertension

Treatment: Personal care assistance (PCA) services 56 hours per week

The insurer denied coverage for PCA services 56 hours per week.

The denial is modified.

This is a patient with chronic medical problems including pulmonary hypertension requiring nasal oxygen. She currently has PCA services 30 hours/week. Under review is the requested increase PCA services 56 hours per week.  

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive status is intact. She is "alert and oriented to person, place and time". The patient is able to articulate safety precautions; "able to verbalize an emergency preparedness plan for example in the event of a fire in the home; member reports she would try to leave the home and then call 911 and seek further assistance; member is also aware that her oxygen is highly flammable and requires need for her to exit immediately in the event of a fire." The patient requires limited assistance for activities of daily living (ADL) tasks including bathing, personal hygiene, dressing and toilet transfers/use. She is frequently incontinent of bladder and continent of bowel. The patient is independent with bed mobility. She uses a (hybrid; manual/motorized) wheelchair or cane for functional mobility. Due to her underlying pulmonary condition, the patient uses a portable oxygen tank with oxygen concentrator. The combination of the patient's intact cognitive status, ability to perform ADL tasks with only limited assistance and her functional mobility, do not support the medical necessity of the requested increase PCA services 56 hours per week. However, increasing PCA to 35 hours/week (5 hours/day) would allow for more consistent daily care and allow the patient the ability to continue living safely at home.  

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 personal care assistance (PCA) services 56 hours per week is modified. Medical Necessity is substantiated for 35 hours/week.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Reconstructive surgery on left foot, secondary to infection and reconstruction of Charcot joint.
Treatment: Skilled Nursing Facility
The insurer denied Skilled Nursing Facility.
The determination is partial overturn.

This is a male patient who recently underwent reconstructive surgery on his left foot, secondary to infection and reconstruction of Charcot joint. He had evidence of an infection. The patient was initially treated and transferred to skilled services for rehabilitation subsequent to the initial hospitalization.
He had a past medical history significant for diabetes mellitus type 2 with neuropathy and Charcot joint with chronic ulcer, osteomyelitis enteropathy.
Services were denied for the following: For continued skilled nursing admission, the patient must be shown a therapeutic response to treatment, participating in rehabilitation, needs skilled services that cannot be managed at a lower level of care and also be making progress in therapeutic services such as physical therapy (PT), occupational therapy (OT). Information provided does not show that the patient needs skilled services that cannot be managed at a lower level care. At issue is the medical necessity of continued skilled nursing facility stay.
Continued inpatient skilled services were medically necessary in part.
The patient has multiple medical problems, most recently left foot surgery from a diabetic Charcot joint with reconstruction and external fixation device. The patient needed ongoing inpatient services for continued frequent wound care services. Physical therapy services were discontinued stating the patient met goals. It was clear from the provided notes stated that the patient's family was either unwilling or unable to take care of him at home with an external fixator device. The patient had evidence of delayed healing with drainage, redness and an abscess after the device was placed. The patient had a high likelihood for subsequent complications without proper wound care. Ongoing wound cleaning 3 times a day was medically necessary for continued healing. There was no notation in the medical record that the visiting nurses/wound care services could actually be arranged on a 3 time a day basis, which is necessary for his treatment recommendations. The patient had the external fixator device removed. No further inpatient services were medically necessary subsequent to that.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/Neuromuscular Disorder
Inpatient Hospital

The patient is a female with known history of diabetes mellitus (DM), hypertension (HTN), and vertigo who presented to the ED after an episode of passing out at work while standing. This was witnessed by coworkers who lowered her to the floor as she became weak. There was no trauma and no seizure. She regained consciousness in a few seconds. Premonitory symptoms of blurred vision with lightheadedness were noted. No other symptoms were reported. Reportedly, she felt the room spinning prior to the episode. No prior history of syncope was noted. She felt dizzy after the episode. No cardiac symptoms were reported including chest pain, and palpitations.

The health plan's determination is overturned in part. At the time of presentation for this patient, the patient could have been considered for observation at a lower level of care with no hx of congestive heart failure (CHF), low HGB (hemoglobin), shortness of breath (SOB), electrocardiogram (EKG) changes or systolic blood pressure (SBP)< 90 based on San Francisco syncope rule. There were no initial concerning relevant past medical history or findings during the emergency room (ER) evaluation prompting an inpatient hospital admission. Even if clinical judgement required monitoring and work up, it should have been completed at a lower level of care. Her initial testing was complete then Nuclear stress test showed reversible ischemia reported as small mild defect in apical wall. Based on this finding, the patient was planned for cardiac catheterization which required transfer to higher level of care. There was then a 3-day delay in cath for reasons that are unclear in the physician documentation. No intervention or hospital treatment was done between except waiting for transfer for cardiac catheterization. These days did not require an inpatient level of care. And when the Cardiac Cath was completed and this required an inpatient level of care based on the abnormal nuclear stress test.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender Dysphoria
Treatment: Gender Affirming Surgery
The insurer denied: Gender Affirming Surgery
The denial is partially overturned.

The patient is an adult male-to-female with a history of gender dysphoria. The patient desires chin revision and breast augmentation. She has been socially transitioning over the past five and a half years. She has been transitioning medically, taking hormone replacement therapy for greater than four years.
The only gender-affirming procedure has been electrolysis. She did have Facial feminization with
1) Frontal sinus reduction and setback;
2) Medial supraorbital rim reduction;
3) Vertical reduction of the lateral orbital rim as well as forehead reduction, frontal bone;
4) Bilateral browlift;
5) Fat grafting to the lips and cheeks;
6) Osseous genioplasty;
7) Bilateral mandible angle reduction;
8) Open rhinoplasty.

The patient reports that the male appearance of her chin, lips, chest and exacerbate her gender dysphoria and cause misgendering. Her surgeon recommends breast augmentation and chin genioplasty revision.

The requested gender affirming surgery is medically necessary, in part.

Specifically, the breast augmentation is medically necessary. However, the genioplasty revision is cosmetic and not medically necessary.
Per the World Professional Association for Transgender Health (WPATH) "Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People" 7th Edition 
guidelines:
Criteria for Breast/Chest Surgery (One Referral)
Criteria for breast augmentation (implants/lipofilling) in MtF (male to female) patients:
1) Persistent, well-documented gender dysphoria;
2) Capacity to make a fully informed decision and to consent for treatment;
3) Age of majority in a given country (if younger, follow the SOC (standard of care) for children and adolescents);
4) If significant medical or mental health concerns are present, they must be reasonably well controlled.

Although not an explicit criterion, it is recommended that MtF (male-to-female) patients undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.
The patient meets these guidelines. She has well documented gender dysphoria and has been on hormone therapy for years. Breast growth with hormone therapy has been maximized. She is the age of majority. Significant mental health concerns are not documented. The requested breast augmentation is consistent with the WPATH (World Professional Association for Transgender Health) criteria and is medically necessary.
The genioplasty revision is cosmetic. The patient has already had a feminizing genioplasty. The records do not include photos that show that the patient's chin appearance deviates significantly from feminine form such that revision is a required treatment for her gender dysphoria. The genioplasty revision, therefore, is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal/other/Spinal Stenosis
Treatment: Inpatient Hospital
The health plan denied the requested inpatient hospital stay as not medically necessary. 
The health plan's determination is overturned, in part.

This is a male with a history of lumbar stenosis. He underwent a lumbar laminectomy L2-3 and L4-5. There were no complications noted on the operative note, specifically no dural tear. The patient ambulated 80 feet unassisted.  The hemovac was removed. The patient was discharged to home. 
At issue is the medical necessity of the inpatient stay.

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

The inpatient stay was medically necessary, in part. The patient was ambulating well unassisted There were no perioperative medical or surgical issues documented. The patient had a hemovac drain that was removed, and it was medically necessary for the patient to be inpatient until this was removed.  The inpatient stay was medically necessary, in part.
Appeal type: Medical necessity
Decision: Overturned

Respiratory System 
Inpatient Hospital 

Diagnosis: Cough/Fever 
Treatment: Inpatient Hospital 

The insurer denied the inpatient stay. The health plan's determination is overturned in part. A 2 day stay was medically necessary. 

The patient is a male with no prior medical history who presented with 3-4 days of cough and fever that had progressed to a temperature of 104 and worsening dyspnea. He was seen at urgent care but sent from there to the emergency department. 

A 2 day stay was medically necessary. The patient presented with evidence of sepsis (fever, WBC, elevated bands, elevated lactate, imaging suggestive of pneumonia) and in respiratory distress. Although his scoring systems suggested a low risk of poor outcome (need for intensive respiratory support, vasopressors; risk of death), he was judged by multiple providers to be ill appearing and at high enough risk of decompensating that he was moved to the ICU. By the next day, he was starting to improve but was still dyspneic and hypoxemic and still needed close monitoring and antibiotics for pneumonia with risk of respiratory decompensation. However, by day 3, symptoms seem to have improved significantly, he was on RA, and he was ambulating without o2 or desaturation. From day 3 onwards, he seemed to have improved (symptoms, exam, and oxygenation), and at this point ongoing inpatient admission was not indicated as his risk was low, he was off o2, and his symptoms had improved and as such did not require close monitoring or inpatient only treatment.