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

Diagnosis: Ears/Nose/Throat. 
Treatment: Surgical Services. 
The insurer denied septoplasty, rhinoplasty with major septal repair, lateral wall implant and inferior turbinate resection. 
The denial is partially overturned.

The patient is a female who was struck by a car and sustained nasal fractures and facial lacerations. She complained of difficulty breathing through her nose; Breathe right strips resulted in partial improvement. Exam revealed a deviated nasal septum to the right and irregular dorsal nasal hump and bilateral inferior turbinate hypertrophy. She has a history of allergic rhinitis and was treated with Flonase nasal spray and saline. She was seen in follow up in one month. Photo documentation demonstrated nasal valve collapse on inspiration. Septoplasty or septorhinoplasty with repair of nasal valve stenosis using Latera, and inferior turbinate reduction are the services under review.

The health plan's determination is overturned in part. 

Septorhinoplasty and inferior turbinate reduction are medically necessary. The use of Latera, a bioabsorbable implant, is not medically necessary. Septoplasty is a part of septorhinoplasty and not medically necessary.
Septorhinoplasty with septal repair is considered reconstructive and not cosmetic. It is related to the documented injury in which she incurred a nasal fracture. The patient failed a one-month trial of saline and Flonase nasal spray meeting maximal medical therapy preoperatively (Watson, 2021). Therefore, septorhinoplasty is medically necessary. Septoplasty is not indicated on its own when septorhinoplasty is performed therefore it is not considered medically necessary. Bilateral inferior turbinate hypertrophy is medically necessary. According to Zapanta (2021) in general he states, indications for inferior turbinate reduction includes subjective nasal congestion due to turbinate hypertrophy that has failed appropriate medical therapy, and this is documented in the clinicals provided. Therefore, reduction of the inferior turbinates is medically necessary.
Repair of nasal valve collapse with Latera, is not medically necessary. According to the manufacturer supporting the cartilage "may" reduce nasal airway obstruction symptoms. In a 2017 study by San Nicolo a cohort of 30, there was improvement in the Nasal Obstruction Symptom Evaluation (NOSE) score of at least one class of five or 20%. At 24 months follow up (San Nicolo, 2018) in 2018, the cohort reduced to 25, and the authors conclude that there was symptom improvement in some subjects. Based upon the peer reviewed medical literature, as there are no comparison studies with the current standard, with long term effectiveness affecting patient health outcomes. Therefore, the Latera nasal implant for the treatment of nasal vestibular collapse is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Excessive skin and subcutaneous tissue. 
Treatment: Excision of Excessive Skin and Subcutaneous Tissue (lipectomy, panniculectomy, abdominoplasty). 
The insurer denied: Excision of Excessive Skin and Subcutaneous Tissue (lipectomy, panniculectomy, abdominoplasty). 
The denial is partially approved. 

The patient is an adult female patient that underwent bariatric surgery 6 years ago. She has lost 90 pounds. She has frequent rashes in her pannus fold that have persisted despite topical treatment with Lotrimin, Mycolog, nystatin, and Difllucan. Panniculectomy is planned. 

A panniculectomy is medically necessary, however, an abdominoplasty is cosmetic and not medically necessary. 

A panniculectomy (15830) is medically necessary. According to the American Society of Plastic Surgeons Position Paper "Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients," "When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. In situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic. Only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically, these procedures are performed to improve appearance and are therefore cosmetic in nature." 
The records indicate that the patient has failed conservative treatment for her longstanding rashes, including treatment by her primary care physician for several months. Photos show rashes and skin breakdown under the pannus fold. A panniculectomy will eliminate her rashes. The patient has failed medical management for months, and panniculectomy is now the most appropriate treatment for her rashes. Therefore, the requested health service is medically necessary. 
However, abdominoplasty is cosmetic. Removal of redundant upper abdominal skin, diastasis repair and umbilical transposition are component parts of an abdominoplasty that are not necessary to treat the rashes. According to the American Society of Plastic Surgeons, "In the case where a panniculectomy is combined with plication of the rectus abdominis muscle and/or translocation of the umbilicus, this may be completed as a single stage procedure but the plication of the rectus abdominis muscle and/or translocation of umbilicus should be considered purely cosmetic and separately billed to the patient." An abdominoplasty is a cosmetic body contouring procedure that will not confer any additional functional benefit for this patient. A panniculectomy with skin resection is sufficient to treat this patient's infections.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing teeth; tooth decay
Treatment: Root canal, tooth #10
Crowns, teeth #s 8-10
Retainer crown, teeth #s 17 & 20
Pontic, teeth #s 18 & 19

The proposed treatment for tooth #10 is medically necessary as well as the proposed treatment for teeth #17-20 is medically necessary.  However, the proposed treatment for teeth #8 and #9 is not medically necessary.  

Tooth #10 needs a root canal treatment and a crown; there is decay present. However, there is no indication for the need for crowns on teeth #8 and #9. There is no decay or fractures in these teeth; therefore they are not medically necessary. The patient is missing two teeth in the lower left. A bridge from teeth #17-#20 is medically necessary to give the patient a full complement of teeth to chew with in the lower jaw. The retainer crowns #17 and #20, as well as the pontics #18 and #19, are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a history of hypertension, reactive airway disease and anxiety, who presented to the emergency department complaining of chest pain.  There were no acute electrocardiographic changes.  Her serum troponin level was elevated.  A chest x-ray showed no acute disease.  She was admitted to the hospital with a diagnosis of non-ST segment elevation myocardial infarction.  The health plan's determination is overturned in part.  The patient required inpatient level of care for 1 day with discharge the following day.
This patient presented with chest pain and a significantly elevated serum troponin level. While she had no acute electrocardiographic changes, this did not rule out an acute infarction.  A normal electrocardiogram has been reported in up to 5% of patients with non-ST segment elevation myocardial infarction.  There were no obvious causes of a falsely elevated troponin level, such as renal failure, sepsis or congestive heart failure.  Until proven otherwise, in the setting of acute chest pain, an elevated serum troponin level must be assumed to be indicative of myocardial injury.  Given the risks associated with acute myocardial infarction, including potentially lethal arrhythmias, heart failure and shock, the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes recommends inpatient admission for patients with chest pain and elevated cardiac biomarkers in whom acute infarction is suspected.  However, given that this patient was found to have no obstructive disease, and her procedure was uncomplicated, she could have been discharged the next day, once she recovered from the procedure.  The safety of same day discharge after cardiac catheterization, even in the setting of percutaneous intervention, has been well established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left hip fracture and replacement, colon cancer, hypertension, muscle weakness, abnormality of gait and chronic pain
Treatment: Personal Care Aide (PCA) services 7 days per week, 24 hours a day live in
The insurer denied coverage for Personal Care Aide (PCA) services 7 days per week, 24 hours a day live in
The denial is modified

 
This is an elderly patient with medical problems that include colon cancer, hypertension and recent hip fracture. She lives alone in a private residence; however, she was in a skilled nursing facility (SNF) at the time the UAS was performed. The insurer approved Personal Care Aide (PCA) 67 hours/week. The request is for PCA service live in, 7 days a week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Moderately impaired- Decisions are consistently poor or unsafe; cues/supervision required at all times." She is totally dependent to maximal assistance for much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and managing her medications. She is also totally dependent for bathing, locomotion and ambulation. Maximal assistance is needed for lower body dressing and toilet transfer/use. She is incontinent of bladder and bowel. Extensive assistance is needed for personal hygiene and upper body dressing. Limited assistance is needed for bed mobility and eating.  

However, the physical and occupational therapy notes at the skilled nursing facility (SNF) documented a higher level of functional ability. According to the therapy notes the patient's transfer ability (locomotion) was at the contact guard (limited) assistance level. She was able to ambulate with a rolling walker and contact assistance. Activities of daily living (ADL) including eating, personal hygiene and upper extremity dressing were at the contact guard to set-up level of assistance. Bathing and lower body dressing were at the moderate (extensive) assistance level.    

The patient's medical condition and functional ability are not at the level as to require the requested PCA services 24 hours/day (live-in). This physician would agree the patient may require additional monitoring, particularly due to her cognitive deficits. However, safety monitoring under PCA 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 can be appropriately provided and maintained by increasing the approved PCA to 12 hours/day, 7 days/week (total 84 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 (PCA) services 7 days per week, 24 hours a day live in services is not substantiated. However, PCA 7 days/week 12 hours/day (84 hours/week) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior cervical discectomy.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is modified.

 
This case involves an adult diagnosed with spinal stenosis of the cervical region who presented to the hospital for a scheduled anterior cervical (C) discectomy and fusion at C3-C4, C4-C5, C5-C6, and C6-C7, with total disc arthroplasty at the same levels. The brief operative note indicated that there were no complications. Records noted the patient had a history of sepsis, type 2 diabetes mellitus, gastroesophageal reflux disease, high cholesterol, hypertension, hypothyroidism, and sleep apnea. Total surgery time was approximately 6 hours with the patient remaining intubated and sedated through the following morning. Her pain was controlled with Robaxin, Tylenol, and Toradol. Her heart rate and blood pressure were stable, and her surgical drain was removed the following day. She was advised to continue incentive spirometry, continue bowel regimen, and advance her diet as tolerated. She had no reports of dysphagia, and her Foley catheter was removed. Lab results showed elevation in the patient's white blood cell count at 14.1 and 14.5, up from the day prior at 13.3. Her hemoglobin levels were low at 11.3 and 11.4 respectively. Hematocrit was also low at 33.2 and 33.8 respectively. Her sodium had normalized, and her surgical site was clean, dry, and intact. She was neurologically intact in the upper extremities. The patient's white blood cell count started improving, although hemoglobin and hematocrit remained low. Her sodium level had also gone down to 133 with serum glucose elevated at 133. Her calcium was low at 7.8, although she remained neurologically intact in the upper and lower extremities. The patient was assessed, she remained neurologically intact in the upper and lower extremities. She reported some incisional pain, but took a few steps the day prior, was voiding freely, passing flatus, and denied chest pain, shortness of breath, abdominal pain, nausea/vomiting, or lightheadedness. Her vital signs were stable with reports of mild/asymptomatic hyponatremia, and hypertension with continued Lopressor. Her hemoglobin A1C was improving, and she would continue weekly Trulicity and Lantus. She will continue Synthroid to address the hypothyroidism, continue proton pump inhibitors to counteract gastroesophageal reflux disease, and was given aspirin 81 milligrams (mg) to be taken daily to prevent deep vein thrombosis. The patient was subsequently discharged.  

It was therefore determined that a denial of coverage for full hospital admission was not appropriate, but denial of coverage for continued admission only, was reasonable. She could have been safely downgraded to lower level of care.

Based on the above, the insurer's denial must be modified. The health care plan acted reasonably in part. The medical necessity for full hospital admission is modified to allow coverage for the first two days and deny the continued stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis and dementia

Treatment is Consumer Directed Personal Assistant Services (CDPAS) Basic-15 minutes for a total of 84 hours per week

The insurer denied coverage for Consumer Directed Personal Assistant Services (CDPAS) Basic-15 minutes for a total of 84 hours per week
 
The denial is modified

The patient is an elderly female with chronic medical problems including osteoarthritis and dementia. She lives alone in a 1-bedroom apartment. She is currently receiving 38 hours/week CDPAS and requesting an increase to 84 hours/week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are "moderately impaired." She requires extensive assistance with bathing, lower body dressing and locomotion. Limited assistance is required for personal hygiene, upper body dressing, and toilet transfer/use. She is occasionally incontinent of bladder and continent of bowel. The patient is independent with bed mobility and eating. Contrary to the assertions of the insurer, there has been a functional decline when compared to the UAS report. At that time, her cognition was only minimally impaired. Limited assistance was required for walking/locomotion. Personal hygiene and toilet transfers required only supervision. The combination of cognitive and functional decline supports an increase in CDPAS. Her condition and functional needs are not at a level or unpredictable as to require the requested 84 hours per week. This physician would also agree that the patient may require increased monitoring. However, safety monitoring (e.g., for dementia) under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.  

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested CDPAS Basic-15 minutes for a total of 84 hours/week is not medically necessary; however, an increase in CDPAS to 8 hours/day, 7 days/week totaling 56 hours/week is medically necessary.  

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 Consumer Directed Personal Assistant Services (CDPAS) Basic-15 minutes for a total of 84 hours per week is modified. An increase of CDPAS to 8 hours/day, 7 days/week totaling 56 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes Mellitus. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the inpatient hospital stay. 
The determination is overturned in part. 

The patient was brought to the emergency department (ED) with a week of polyuria and polydipsia, three days of non-bloody vomiting, and worsening fatigue. His mother has type 1 diabetes. His vital signs were normal. His glucose was 458, potential hydrogen (pH) 7.25; urine showed a large amount of sugar and ketones. He received two one-liter normal saline boluses and 10 units of insulin intravenous (IV), and was admitted to the Pediatric Intensive Care Unit (PICU) for management of new onset type 1 diabetes. The next day, he was doing well on insulin, was feeling much better, and was transferred to the floor. A subcutaneous insulin regimen was developed including a sliding scale regimen and diabetes education was underway. He continued to feel well; the nursing staff documented that he was successfully checking his sugar, calculating his sliding scale, and administering his insulin. He was discharged. 

At issue is the medical necessity of an inpatient stay. 

The inpatient stay was medically necessary, in part. 

Management of new onset diabetes is first to stabilize the clinical situation with fluids and insulin to reverse the ketoacidosis and correct any other metabolic abnormalities. Once the patient is stable, management includes continued insulin and the initiation of diabetes education. This education is medically essential, as both diabetic ketoacidosis (DKA) from insufficient insulin and hypoglycemia as a result of overdose of insulin are life threatening. Where this education occurs, however, depends on the resources of the center. Before the development of elaborate and well-resourced outpatient diabetes education programs in some areas, continued hospitalization after stabilization for diabetes teaching was standard of care. In many centers, it remains standard of care. In the center where this patient was admitted, the practice continues to be inpatient diabetes education for new onset diabetics. The length of the hospitalization depends on how long it takes to stabilize and then how long it takes to provide sufficient education that a discharge home is safe. This patient's clinical situation turned around fairly promptly, by the morning after the PICU admission. According to the clinical notes, the education went smoothly as well, and the notes indicate he had learned sufficiently to be discharged. The stay was medically necessary in part as the last day of the stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ciliary dyskinesia (PCD), asthma, chronic cough, bronchiectasis, and Kartagener's syndrome

Treatment Pulmozyme

The insurer denied coverage for Pulmozyme

The denial is modified

The patient has a history of primary ciliary dyskinesia (PCD), mild persistent asthma, chronic cough, chronic sinusitis, multiple nasal polyps, and Kartagener's syndrome. The patient presented Pediatric Pulmonology, for a follow-up visit. He has bronchiectasis and despite daily intensive airway clearance regimen with albuterol and a chest vest he has a persistent cough. Pediatric Pulmonology states that the patient will significantly benefit from the use of Pulmozyme to break down neutrophils deoxyribonucleic acid (DNA) and decrease viscosity of secretion facilitating its removal from the lower airway. In addition, the doctor has performed a bronchoscopy which demonstrated the presence of purulent airway secretions which grew out bacteria. The BAL (bronchoalveolar lavage) specimen demonstrated the presence of a high white blood count in the airway secretions.

The patient has Kartagener's syndrome with situs inversus, ciliary dyskinesis and bronchiectasis. He has been on daily airway clearance with persistent respiratory symptoms and a cough. His bronchoscopy specimen has elevated neutrophils and bacteria present. 

It would be appropriate for Pediatric Pulmonology to prescribe pulmozyme for a 3 month period to monitor for the effectiveness of this treatment to control the patient's symptoms. PCD is a progressive disease and if pulmozyme is found to be effective in controlling his daily cough and purulent sputum it would be an effective addition to his daily therapy for long term use to prevent worsening of bronchiectasis over time.

Although clinical studies have not been performed in an adequate study in patients with PCD to document the benefit for this diagnosis, there are multiple case reports and data indicating frequent clinical use of this therapy prescribed by physicians at PCD Foundation care centers Several case reports of DNase in PCD suggest possible benefit when used for both short and long-term periods

Since this patient with PCD has ongoing symptoms and bronchoscopic evidence of infection and inflammation, it would be appropriate for Pediatric Pulmonology to prescribe this medication for a 3 month trial period to monitor for improvement in patient's lung function, sputum culture and clinical symptoms. If there is improvement during this trial period then Pediatric Pulmonology can document this improvement and submit this data to the insurer in order to determine the appropriateness of ongoing treatment with this daily inhaled medication.

The health plan did not act reasonably in the best interest of the patient.

Based on the above, the medical necessity for the Pulmozyme for primary ciliary dyskinesia (PCD), asthma, chronic cough, bronchiectasis, and Kartagener's syndrome is substantiated. The insurer's denial is modified to allow a 3 month trial of pulmozyme to determine efficacy.