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

Diagnosis: Cognitive decline, hyperlipidemia, abnormal gait, and osteoarthritis

Treatment: Home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (live in)

The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (live in)

The denial is modified.

 
This is an elderly patient with hypertension, osteoarthritis and dementia. She lives alone in a 2-bedroom apartment. The insurer approved home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 44 hours per week and the request is for 24 hours per day (live in) due to cognitive decline.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as minimally impaired. She is totally dependent to maximal assistance for much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She requires maximal assistance for bathing and lower body dressing. Extensive assistance is needed for personal hygiene, upper body dressing and toilet transfer/use. The patient is frequently incontinent of bladder and occasionally incontinent of bowel. Limited assistance is needed for locomotion/ambulation. She requires supervision for bed mobility and eating. There have been no reported falls over the prior 90 days. Her functional ability has declined compared to the prior UAS. 

The patient's medical condition and functional ability are not at the level or unpredictable as to require the requested PCA 24 hours/day live-in. However, her functional impairments support an increase to 12 hours/day, 7 days/week (total 84 hours). The patient may require additional monitoring; particularly due to her cognitive decline. However, safety monitoring under personal care services / home health care(PCS/HHC) does not include monitoring an individual (with dementia) when no other Level I or Level II personal care service tasks are being provided.  Based on the records reviewed, attention to the patient's functional needs are more appropriately provided and maintained by increasing PCS / HHC to 12 hours/day, 7 days/week (total 84 hours).

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 home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (live in) services is not substantiated. 

However, increasing home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 12 hours per day, 7 days/week (total 84 hours) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: severe capsular contracture, grade IV on the left breast

Treatment: CPT code 19380 (revision of reconstructed breast)

The insurer is denied coverage for CPT code 19380 (revision of reconstructed breast)

The denial is modified. 

This female patient has a history of thyroid disease and breast cancer.

According to the American Society of Plastic Surgery "CPT Corner" article titled "Breast reconstruction coding: Everything you need to know" (June 2009), implant removal is a component part of implant replacement. To quote directly; "Implant removal (19328) is included in implant replacement procedures - one cannot place a new implant in, unless the previous implant is removed."  In addition, code 19380 is not medically necessary because the records do not document any additional procedures beyond implant replacement (19342) and capsulectomy (19370).
The insurer's denial of coverage for the CPT code 19380 [revision of reconstructed breast (e.g., significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant based reconstruction)]- modifier 50 [bilateral procedure], CPT code 19370 [revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy]- modifier 50 and 59 [distinct procedural service], CPT code 19340 [insertion of breast implant on same day of mastectomy (i.e., immediate)]- modifier 50, and CPT code 19328 [removal of intact breast implant]- modifiers 50/59 performed on 8/12/20 is modified. Medical Necessity is partially substantiated. Approve 19342 and 19370 and uphold denial of 19328 and 19380.

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

The carrier's denial of coverage for the CPT code 19380 (revision of reconstructed breast) is modified.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Aneurysm
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is overturned, in part. 

The patient is a female with obesity, fibromyalgia. She was admitted for flow diverter stent placement with left MCA (middle cerebral artery) lenticulostriate origin 3x2mm (millimeter) aneurysm. 

The patient was recommended flow diversion based upon location. The patient underwent this procedure and was admitted to stepdown postoperatively. She received an aspirin load due to platelet mapping levels being low. The patient was discharged home on postoperative day 2.

Yes, in part. The Inpatient admission was medically necessary, in part.

Specifically, inpatient admission for admission day 1 was medically necessary. Inpatient admission for subsequent admission days was not medically necessary.

On admission day 1 date of service, the patient was immediately postprocedure. It was appropriate to keep the patient on this date to perform adequate neurological checks and monitor for any complication that would warrant further neurosurgical intervention.

On admission days 2 and 3 there is insufficient evidence provided that these dates required acute inpatient level of care. The patient did not have any issues that would warrant acute inpatient stay, such as severe pain requiring IV (intravenous) medications, close neurochecks, or other issues that would warrant acute stay. These dates were not medically necessary at the acute inpatient level, based upon clinical documentation provided.

The immediate postoperative period does require acute inpatient stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiomyopathy, bronchitis and hypertension
Treatment: Personal care worker (PCW) services 7 days per week, 24 hours per day, live in; 91 hours per week.
The insurer denied coverage for personal care worker (PCW) services 7 days per week, 24 hours per day, live in; 91 hours per week.
The denial is modified.
 
This is an elderly patient with chronic medical problems including cardiomyopathy, bronchitis and hypertension. She lives alone in a private residence. The insurer approved personal care worker (PCW) services 6 hours per/day, 7 days/week and the request is for PCW services 7 days/week, 24 hours/day, live in; (91 hours/ week). 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as modified independent. She reportedly requires extensive to maximal assistance for much of her Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She requires extensive assistance for bathing and lower body dressing. Limited assistance is needed for personal hygiene, upper body dressing and eating. She is independent with bed mobility. Extensive assistance is needed for toilet transfer/use.  Her doctor indicated in his note the patient "can't really ambulate on her own." However, according to the UAS subsequently noted the patient requires only limited assistance for locomotion and ambulation. In addition, and according to the home physical therapy notes also subsequently dated, the patient is at the supervision level for transfers and ambulation.  

The patient's medical condition, physical limitations and functional decline are not at the level or unpredictable as to require the requested PCW services 24 hours/day live-in.  However, Ms. Kane's functional ability has significantly declined when compared to the previous UAS report and supports increasing PCW services to 9 hours/day, 7 days/week totaling 63 hours/week. The patient may benefit from additional monitoring; particularly due to her reported balance deficits and falls risk. However, safety monitoring under PCW does not include monitoring an individual (e.g., with balance deficits) when no other Level I or Level II personal care services task is being provided. Based on the records reviewed, attention to the patient's functional needs are more appropriately provided and maintained by the increasing PCW services to 9 hours/day, 7 days/week totaling 63 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 worker (PCW) services 7 days per week, 24 hours per day, live in; 91 hours per week services is not substantiated. However, increasing personal care worker (PCW) services to 9 hours/day, 7 days/week totaling 63 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizoaffective Disorder, Suicidal Ideations
Treatment: Continued inpatient mental health treatment
The insurer is denied coverage for continued inpatient mental health treatment. 
The denial is partial overturned. 
This is a female patient who was admitted to the inpatient mental health treatment due to psychotic symptoms. The patient had disorganized thinking and behavior as she was staggering in the street. The patient reportedly was non-compliant with her medications, and exhibited symptoms of psychomotor retardation, drooling, slow speech, uncooperativeness, poor eye contact, depressed mood, and feelings of hopelessness, inability to care for self (i.e. not bathing or toileting), and not eating with 40 pounds of weight loss in three months. The patient was admitted and was treated with risperidone, Haldol, and gabapentin. The patient improved and was discharged.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior, or inability to adequately care for basic needs are candidates for hospitalization. The chart notes reported that this patient was unable to care for self until date of service. Notes reported that the patient was still unable to care for self as she was isolative, had minimal interaction, depressed mood, hopelessness, constricted affect, and was struggling with balance issues. Notes reported gradual improvement as the patient required encouragement with caring for her basic needs including showering and changing clothes, and she was still isolative with minimal interactions. After two more days of improvement to the point of feeling better further chart notes no longer supported this patient's need for 24-hour hospital treatment. Notes reported that the patient was feeling much better, had improvement in showering and changing clothes, and she was accepting medications, was better related with staff, selective in interactions with peers, participating in some group activities, and was calm, had fair grooming, normal eye contact, and denied suicidal and homicidal ideation, hallucinations, or delusional thinking. Notes reported that the patient was feeling better and was discharged.  There were no further reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in an inpatient psychiatric treatment setting then or that could not be treated in a less restrictive setting then. Thus, while inpatient mental health treatment was medically necessary continued inpatient mental health treatment was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment to disapprove coverage for the last five days but did not act in the best interest of the patient for denying coverage for the first seven days.

The carrier's denial of coverage for continued inpatient mental health treatment should be partial overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: autism
Treatment: Additional 35 Hours of Direct Applied Behavior Analysis (ABA) Therapy and 7 Hours of Supervision 
The insurer denied Additional 35 Hours of Direct Applied Behavior Analysis (ABA) Therapy and 7 Hours of Supervision 
The health plan's determination is overturned in part. 

The patient is a male who has been diagnosed with autism spectrum disorder. According to the documentation provided, he has been receiving applied behavioral analysis (ABA) therapy for over 9 years. At present he receives 12 hours per week of direct ABA therapy and attends an ABA-based school. His ABA therapist is requesting an additional 35 hours of direct ABA and 7 hours of supervision to address an increase in aggressive behavior and elopement.

Five (5) hours of direct ABA per week and for the next 6 months, with an additional 4 hours per authorization period for supervision are medically necessary.
Documentation by the ABA therapist, of the frequency and severity of elopement and aggressive behaviors is incomplete. The mother's description of the patient's behaviors is concerning, however, particularly as injury to other family members is reported. The Mother reports that his neurologist has recommended a minimum of 15 hours' direct ABA per week. The 15 hours of direct ABA per week and for the next 6 months, with an additional 4 hours per authorization period for supervision are indicated. Documentation of behavior frequency and severity by the ABA therapist must be improved and completed. Re-evaluation of the response to therapy intervention should be performed at the end of 6 months.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Traumatic Brain Injury.

Treatment: Acute rehabilitation (inpatient medical rehabilitation).

The insurer denied coverage for continued acute rehabilitation hospital admission.

The denial is modified.

This is a young adult who was involved in a motorcycle accident and sustained a traumatic brain injury. He was subsequently admitted to a rehabilitation facility for acute inpatient rehabilitation. He developed a gastrointestinal (GI) bleed and transferred back to the acute hospital. He was readmitted to the acute rehabilitation facility and approved by the insurer. Under review is the medical necessity of continued stay, acute rehabilitation (inpatient medical rehabilitation). 

The patient was initially an excellent candidate for acute inpatient rehabilitation. He has physical and cognitive deficits that were potentially amenable to comprehensive rehabilitation (including physical, occupational and speech therapy); and requiring at least 3 hours therapy/day. His inpatient rehabilitation hospital course was complicated; requiring transfer back to the acute hospital for GI bleed and readmission to the acute rehabilitation facility for continued inpatient treatment. Subsequent treatment included intravenous (IV) antibiotics for suspected aspiration, tracheostomy management and injection procedures for spasticity management as well as continued comprehensive skilled multi-disciplinary therapy services.  

Unfortunately, the provision of multi-disciplinary (medical, nursing and rehabilitation therapy) services failed to result in significant functional improvement to support continued inpatient acute rehabilitation services. His acute medical problems had stabilized. The patient has remained otherwise fully dependent to maximal assistance for activities of daily living and functional mobility. In addition, there were no subsequent acute medical interventions or complicated nursing care issues to support continued inpatient rehabilitation.

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 ten additional days of acute rehabilitation (inpatient medical rehabilitation) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of nephrolithiasis and presented to the emergency department (ED) on 5/5/19 with complaints of (c/o) of palpitations x 3 days. The patient reports associated shortness of breath, blood tinged emesis and generalized weakness and noted subjective fevers, dysuria and suprapubic pain. The patient was admitted to the hospital. 

The health plan's determination is overturned in part. The inpatient stay was medically necessary for 2 days. However, as of day 3, the patient no longer required an inpatient level of care. Urinary tract infection with known urologic obstruction in setting of vomiting and unable to take PO would warrant inpatient monitoring to ensure patient tolerating antibiotics and does not have rapid progression of infection with sepsis and renal damage. As of day 3, the patient had been seen by urology who felt the obstruction did not need inpatient intervention was no longer vomiting and culture results showed pan sensitive E. Coli. Therefore, the patient was medically stable for discharge.
Appeal type: Medical necessity
Decision: Overturned

The patient was  brought to the emergency department with one week of a fever, non-bilious/non-bloody vomiting, and non-bloody diarrhea. She received two normal saline boluses, appeared better, took formula by mouth, and was sent home with follow up instructions. The parents returned with her to the ED about twelve hours later, for a possible febrile seizure versus shaking chill.  The baby appeared well except for dry mucus membranes. She was given two normal saline boluses and begun on two-times maintenance intravenous (IV) fluids and admission to the hospital was arranged. The health plan's determination is overturned in part.
This baby returned to the ED twelve hours after having received significant IV fluid therapy in the ED. Upon representation, her fluid status was worse, as evidenced by the dry mucus membranes and the much lower bicarbonate level. Given the representation with worsening dehydration despite appropriate therapy, now with significant acidosis, further IV fluid therapy and acute hospitalization was medically necessary. That first day, acute criteria were met and acute inpatient hospitalization was necessary. By the next day, however, she was improved and taking fluids by mouth. She no longer had clinically significant dehydration and could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient arrived at the emergency department (ED) via Emergency Medical Services  with complaint of abdominal pain, nausea and vomiting of 5 days duration. Her past medical history included prior gastric bypass, cholecystectomy, hernia repair, and a diagnostic laparoscopy for small bowel obstruction.The health plan's determination is overturned in part. The inpatient hospital stay was medically necessary. The records support that inpatient admission was medically necessary and consistent with standards of care for 4 days. The records do not support the need for continued inpatient admission beyond 4 days. This patient presented with abdominal pain, nausea and vomiting. The initial evaluation identified epigastric tenderness, a leukocytosis, and an abnormal CT scan consistent with acute pancolitis. The patient was started on IV antibiotics (Cipro and Flagyl). The patient  required IV fluid and IV antibiotics, imaging with CT scan and IV analgesia. This care and treatment spanned a period of 2 days and was most appropriately performed with an inpatient designation. Colitis as indicted by CT scan imaging carries the potential for clinical deterioration and was appropriately monitored in the inpatient setting for 4 days. Then on the 4th day, the patient had demonstrated clinical improvement such that the patient could have reasonably been discharged from the inpatient setting with plans for a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Schizophrenia
Inpatient Mental Health

The patient is a male with a diagnosis of paranoid schizophrenia (PS). Case notes document that the patient has suffered from chronic severe PS requiring multiple past admissions. Two days before the admission under review, he was referred to the Methodist Hospital and released after evaluation. His admission by emergency services was due to agitation and aggression, and the abnormal behavior of trying to burn down his residence out of anger. On initial evaluation, he was floridly manic and uncooperative, irritable and unkempt, with suicidal ideation (SI) and auditory hallucination (AH).

The health plan's determination is overturned in part. Inpatient mental health was indicated for 11 days. After day 11, the patient could have been cared for at a lower level of care. The remaining 45 days would not be medically necessary. 

For example, the patient was still poorly groomed. His ADLs (activities of daily living) were poor. He had poverty of speech. He was paranoid, delusional, with poor insight and judgment. He continued to be poorly groomed, with continued poverty of speech. He was judged to be at risk for readmission if discharged. Distinct improvement was noted. The patient said he felt fine. He was euthymic and calm. He had no SI or HI. He was experiencing no auditory hallucinations. His affect was still flat, however. He was started on IM depot risperidone Consta. On day 11, he was judged to be at his baseline. He was compliant with his meds. He showed no abnormal behaviors. He continued to be euthymic. Therefore, he could safely and with good medical judgment be discharged to a less intensive level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing tooth
Issue under review: Crowns

Determination:
The crowns are medically necessary, in part.

Specifically, the requested procedures are medically necessary for teeth 3 and 5. The patient only has one missing tooth in his mouth (tooth #4). Therefore, replacing that tooth with a bridge from tooth 3 to 5 is a viable option to correct this situation. Teeth 3 and 5 would be the anchor teeth for a new bridge. To replace the one missing tooth with a partial denture is absolutely not the correct plan. 

The requested procedures are not medically necessary for teeth 8 and 9. There is no evidence showing the need (e.g., recurrent decay or fracture) on these teeth for new crowns. The existing crowns look fine, and there is no evidence presented showing the need to replace them.