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

Diagnosis: Respiratory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient admission. 
The denial is overturned in part.  

The patient is a female with oxygen dependent chronic obstructive pulmonary disease (COPD), prior cerebrovascular accident (CVA), substance and alcohol use who presented to the hospital for abdominal pain. She has been admitted multiple times previously for similar symptoms. The patient described generalized abdominal pain, worsened with meals. She had been seen by gastroenterology and had a fairly comprehensive work-up in the past and carries the diagnosis of cannabinoid hyperemesis syndrome. She  had two recent upper endoscopies. She has a history of (H/O) fundoplication for reflux.

On exam, vitals were stable, but she appeared uncomfortable due to pain and was frequently vomiting. Abdomen was tender in the epigastrium without guarding or rebound. Imaging identified a right lower lobe (RLL) infiltrate thought to be from aspiration. Computed tomography (CT) of abdomen otherwise normal. In the emergency room (ER) after morphine, Zofran, Haldol and proton pump inhibitor (PPI) the patient appeared in no apparent distress (NAD). She was started on antibiotics for pneumonia. On the second hospital day the patient denied further nausea or vomiting. She continued to have epigastric tenderness to deep palpation. She had no events and no specific complaints.
The subject under review is the medical necessity for the inpatient hospital admission.

The health plan's determination is overturned in part. 

The inpatient hospital admission was medically necessary, in part. Based on the record, the patient required one day of inpatient care. The specific indication for inpatient admission is that the patient had a new pulmonary infiltrate in the setting of advanced COPD. The patient had an elevated white blood cell (WBC) count and lactate level. In addition, for the first 24 hours the patient was unable to take by mouth (PO). By the second hospital day the patient had made significant improvement with less abdominal pain and no progression of pulmonary symptoms.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: disc herniation

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is modified

This is an adult male who presented to the emergency department complaining of severe lumbosacral pain radiating to the right leg for 6 days. He took Tylenol extra strength and oxycodone IR (instant release) without relief of symptoms. He was scheduled for surgery the following week. However, surgery was rescheduled for the following day after his physician noted a large L (lumbar) 2-L3 central disc herniation with inferior migration. The patient was admitted for pain control and preoperative work-up prior to the L2-L3 laminectomy/discectomy. His pain control could have been rendered on an outpatient basis or under observational care. The surgery could have been completed on an outpatient basis as there were no complications following the procedure. An appeal letter was submitted stating that in addition to the L2 laminectomy, the patient required removal of an extra mass and an L3 revision with partial L4 laminectomy, excision of a migrated herniated disc behind the L3 vertebral body, and posterior lateral fusion with local autograft at L2-L3. Based on the risk for complication that could potentially affect neurological function, the patient required a higher level of monitoring and care. This review pertains to the denial of coverage for inpatient admission.

The Milliman Care Guidelines state that patients with low back pain typically will require hospitalization when they have severe pain that cannot be managed in the emergency department, have a suspected spinal infection, or have a suspected cause that requires inpatient treatment such as aortic dissection or spinal cord impingement. The guidelines state that in terms of lumbar fusion, the goal length of stay is 2 days postoperative.

Based upon the provided information, the prior determination is partially overturned to allow for partial coverage for the inpatient admission.

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 inpatient admission is modified. Medical Necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic /musculoskeletal/joint problem.
Treatment: Inpatient hospital.
The insurer denied the entire inpatient hospital stay.
The denial is partially overturned.

This case describes a patient who underwent a right primary total knee replacement surgery. The records document that the patient has a history of hypertension and that she failed conservative treatment for advanced osteoarthritis of the right knee.
Yes, in part, the requested inpatient hospital stay was medically necessary for this patient. Based on the provided medical records and the recommendations of the current, peer-reviewed orthopedic literature, the inpatient hospital admission was medically necessary for this patient for 2 nights. The two additional days of inpatient care were not medically necessary.
The rationale for this determination is based upon the provided medical records which document that this patient underwent primary right total knee replacement surgery. The progress notes subsequently documented that the patient had a reported pain level of 10/10 and was not able to participate in her afternoon physical therapy session due to her increased pain level after surgery. The records then document that the patient received appropriate pain medications and was able to participate more fully in physical therapy the following day.  In fact, the patient was able to ambulate 30 feet. The patient  was able to negotiate 4 stairs in therapy that day as well. The recommendation of the therapy department was for discharge to home with home physical therapy based upon  progress. Based on the documentation the inpatient hospital stay was medically necessary for appropriate pain control. The two-night hospital admission was also medically necessary to allow sufficient progress with supervised physical therapy such that the patient could safely continue her recovery at home. The additional two night inpatient stay, however, was not medically necessary based on the provided medical records.
The medical necessity of the inpatient hospital stay for two nights is established based on the provided medical records and is consistent with the recommendations of the current, peer-reviewed orthopedic literature as published by Xu and colleagues and by Springer and associates.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastrointestinal Bleeding
Treatment: Inpatient Hospital. 
The health plan denied the inpatient stay. 
The health plan's determination is partially overturned.


The patient is a male admitted to the hospital. The patient has a history of gastric bypass and presented with rectal bleeding and vomiting; the vomit contained blood as well. The patient later admitted he did not have blood in his stool and was constipated. The patient also endorsed epigastric pain. One month prior to arrival an esophagogastroduodenoscopy (EGD) apparently showed a "stomach ulcer". He was lightheaded and dizzy. On evaluation in the emergency room (ER) the patient's vitals were stable. Heart rate (HR) = 62 beats per minute (bpm). Initial hemoglobin = 7.9 (patient is with chronic anemia). The patient received 1 unit of blood in the ER. His hemoglobin responded @ 10. He was started on Proton-pump inhibitors. The patient underwent an EGD which revealed 2 very small ulcers in the gastric remnant. The patient was uneventfully discharged.
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is overturned, in part. In my opinion, 1 day of observation level of care was medically necessary. Inpatient hospital admission was not medically necessary.

No. After detailed history and additional supplemental information became available (vital signs, admitting complete blood count (CBC)) it was clear that the patient was not having a significant gastrointestinal (GI) bleed. The patient remained hemodynamically stable in the ER and responded appropriately to a red blood cell (RBC) transfusion. It was very reasonable to admit him as at an observation level of care for 1 day, but an inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, heart disease, heart failure, hypertension, hyperlipidemia, osteoarthritis, benign prostatic hypertrophy (BPH), and glaucoma
Treatment: Consumer Direct Personal Aide Service (CDPAS) 7 days x 12 hours x 2 shifts 
The insurer denied coverage for CDPAS 7 days x 12 hours x 2 shifts
The denial is overturned in part

The patient is of advanced age and has chronic medical problems including diabetes, heart disease and glaucoma. He lives alone in a private residence. The caregiver is his grandson. Under review is the requested increase CDPAS 7 days x 12 hours x 2 shifts. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive status is described as "minimally impaired." He refuses to use his Personal Emergency Response System (PERS). However, he is "able to call his daughter in case of emergency." The patient requires extensive assistance for bathing/dressing and limited assistance for personal hygiene. He is independent for toilet transfers and limited assistance for toilet use. He is frequently incontinent of bladder and infrequent of bowel. The patient is independent with bed mobility and transfers. He is able to ambulate with a cane. His gait is unsteady, and he has fallen several times. He was hospitalized after a recent fall. He currently has CDPAS 53 hours/week. The combination of the patient's modest cognitive deficits, and modified independence with functional mobility do not support the medical necessity of the requested CDPAS increase 7 days x 12 hours x 2 shifts. However, his recent functional status decline and multiple falls which included Emergency Room visits and hospitalization, support an increase CDPAS to 84 hours (12 hours/day, 7 days/week); allowing the patient the ability to continue living safely at home. 

The healthcare plan acted reasonably in part. From a physical medicine and rehabilitation perspective, the requested CDPAS 7 days x 12 hours X 2 shifts, is not medically necessary. However, a CDPAS increase to 84 hours (12 hours/day, 7 days/week) is medically necessary. 

The insurer's denial of coverage for Consumer Direct Personal Aide Service (CDPAS) 7 days x 12 hours x 2 shifts is modified. Medical Necessity is not substantiated for 12-hour split shift/7 days a week. However, 12 hours/day 7 days a week is medically necessary.

The insurer's denial of coverage for Consumer Direct Personal Aide Service (CDPAS) 7 days x 12 hours x 2 shifts is modified as noted above.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: disorganized schizophrenia.
Treatment: Mental Health Inpatient
The insurer denied inpatient mental health treatment. The health plan's determination is overturned in part. 6 additional days with discharge on the 7th day were medically necessary. 

The patient is a woman with diagnoses of disorganized schizophrenia (DSCZ) and diabetes mellitus II (DMII). The patient was brought by Emergency Medical Services (EMS) to the hospital, with the EMS activated by her case worker. The concern was that she was not adequately caring for herself. On mental state examination, the patient was documented to be euthymic, without suicidal or homicidal ideation; she denied auditory hallucination (AH) but most likely she was responding to internal stimuli. She showed poor insight and poor judgment. Her feet were dirty, and she was malodorous. She was not taking any medications for her DSCZ or her metformin.

This patient's DSCZ was chronic and severe. She was not taking care of her serious medical disorder, DMII, or of her activities of daily living (ADL) in general and appeared to be in denial of her DSCZ. She was not taking any psychotropic medication. The question is how much improvement was necessary to safely discharge the patient with good medical judgment. She was still disheveled and unkempt. She was isolative with poor ADLs. The patient was euthymic, denying AH, even though she may have been continuing to experience them. She never stopped talking to "no one." After education about the need to take her medications, she promised to take them including her psychotropic medications. She was documented to say she was getting better and feeling better. This was an indication of some improvement, but her anti-psychotic medication was not considered adequate. She was transitioned to Haldol. She was taking her medication as directed. While she would most likely experience continued symptoms of DSCZ in any context, the fact that she showed improvement overall and some awareness of the need to take both her medical and psychiatric medications, her care could continue in a less restrictive environment.
On the 7th day, the patient could be discharged with good medical judgment, in accord with current standards of best care, and in accord with the medical literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned in part.

The patient has a history of hypertension, hyperlipidemia, diabetes, human immunodeficiency virus (HIV) and gastroesophageal reflux disease (GERD) and presented to the emergency room (ER) with chest pain and dizziness. She also complained of a headache. Her blood pressure was 137/77 millimeters of mercury (mmHg), pulse 73 beats per minute (bpm) and respiratory rate 18. An electrocardiogram (EKG) showed no ischemic changes. The troponin was 0.01.
She was admitted, and treated with nitroglycerin and aspirin, with improvement of the chest pain. A head magnetic resonance imaging (MRI) scan was normal. She ruled out for a myocardial infarction with negative serial troponins. An EKG showed left ventricular hypertrophy (LVH) with inferior T wave inversions. However, there is a note that the leads were misplaced, and after corrected lead placement, the EKG was back to baseline. An echocardiogram (ECHO) showed normal left ventricular function and wall motion. She underwent a cardiac catheterization with no obstructive disease noted. Medical management was recommended and she was discharged. At issue is the medical necessity of an inpatient stay.

Inpatient admission was medically necessary in part. The patient had chest pain, suspected to be anginal, despite negative cardiac enzymes and equivocal EKGs. She had several coronary risk factors. She had persistent symptoms of chest pain, suspected to be anginal, which were relieved with nitroglycerin, but recurred during the admission. She underwent diagnostic coronary angiography. Inpatient admission is indicated for a diagnosis of unstable angina, with new onset chest pain, relieved with sublingual nitroglycerin. The patient meets Milliman Criteria for inpatient admission as she had ischemic symptoms with accelerating tempo of symptoms in the preceding 48 hours.
However, the patient could have been discharged following the cardiac catheterization which did not show any acute obstructive coronary lesions.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Musculoskeletal/Orthopedic. 
Treatment: Inpatient. (custodial care)
The insurer denied: custodial care (long term care). 
The denial is partially overturned.

The patient is a female with recent medical history significant for right 3rd and 4th metatarsal diabetic ulcer complicated by osteomyelitis who was admitted to a Rehabilitation Center. Long-term placement became effective. The subject under review is whether custodial care (long term care) was medically necessary for this patient.

The health plan's determination is partially overturned.

Custodial Care (Long Term Care) was medically necessary for this patient in part.
The patient is a female with recent medical history significant for right 3rd and 4th metatarsal diabetic ulcer complicated by osteomyelitis. Review of documentation noted the patient required maximum assist (MAXA) for bed mobility, was dependent with sit to stand transfers, required maximum assistance with hygiene/grooming and lower body dressing. She was also dependent for bathing. This level of assistance supports the need for 24 hour care and, therefore, Custodial Care/Long Term Care was medically necessary and appropriate. This opinion is further supported by the nursing note  which noted that the patient found on the floor of her room. Documentation noted that resident said she had been trying to get back to bed without assistance when her knees buckled, and she fell. Continued Custodial Care/Long Term Care, though, is not supported for all dates. The reason being that the patient was stand by assist (SBA) for bed mobility, contact guard assist (CGA) with transfers and ambulating 50' using wheeled walker (WW) with minimal assistance (MINA). Additionally, the patient was now CGA bathing, set-up for hygiene/grooming and CGA for lower body dressing. She had also progressed from dependent for toileting to CGA. Lastly, therapy noted that patient lived with family and while it did note that the home was a two story house documentation did not state that there were any stairs required to enter the home and the patient was supervision for wheelchair mobility. Therefore Custodial Care/Long Term Care was medically necessary only in part.
Appeal type: Medical necessity
Decision: Overturned

The patient is pregnant and presented to the emergency department (ED) with complaints of nausea / vomiting / epigastric pain and chest pain (pain localized to the area under right breast). The patient reported cold symptoms " on and off " and was previously advised by her primary medical doctor (PMD) to use Tylenol cold. The patient was given intravenous (IV) hydration, IV Zofran, and IV Pepcid. In view of suspicion for preeclampsia and preterm labor with advanced cervical dilatation, the patient was admitted to L&D (Labor and Delivery); started on magnesium sulfate; and received steroids for fetal lung maturity.

The health plan's determination is overturned in part. The Inpatient Hospital Admission was medically necessary for the patient for 2 days. Based on provided clinical information, the patient presented with chest pain, nausea and was noted to have proteinuria and elevated transaminases. In the setting of proteinuria and elevated transaminases, the suspicion for preeclampsia (particularly - partial HELLP syndrome) was reasonable, consistent with literature (as 25 % of cases of HELLP or partial HELLP syndrome occur in normotensive patients) and with generally accepted standards of practice. The patient's symptoms were at no point suspicious for hyperemesis gravidarum. By the third day, the patient's transaminases normalized, there was no further suspicion for HELLP / partial HELLP syndrome, and therefore, continued acute inpatient stay beyond the 2nd day was not medically necessary as the 24 h urine collection could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: DVT (deep vein thrombosis) 
Treatment is an inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is modified.

According to the clinical documentation provided for review, the patient is a male with the medical diagnoses of non-Hodgkin's lymphoma, in remission, autoimmune hemolytic anemia, and multiple deep vein thromboses (DVTs). The patient presented to the emergency room (ER) with complaints of right leg pain, ecchymosis, and swelling. The patient's computerized tomography (CT) scan showed a right thigh hematoma. There was bleeding suspected, and the patient was transfused. A DVT was also diagnosed at that time. An inferior vena cava (IVC) filter was placed. 

This was not a simple non-complicated DVT, but one caused by a significant hematoma. However, the entire admission was not necessary. Once the IVC filter was placed, the patient could be safely discharged to complete outpatient anticoagulation, or an oral anticoagulant could have been used on an outpatient basis. The patient's Hb (hemoglobin) remained at 8.2 to 8.3 for the next several days. Even if that may have been an issue, the observation level would have been appropriate. Therefore, the request is partially approved and medically necessary for this patient. 

"The purpose of this pictorial essay is to review different etiologies for lower extremity pain encountered on lower extremity venous sonography including acute deep venous thrombosis, chronic post-thrombotic change, central venous disease, common arterial pathologies, and nonvascular abnormalities." (Naringrekar, et al., 2019).

"A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the leg, but can occur in the veins of the arms and the mesenteric and cerebral veins. Deep-vein thrombosis is a common and important disease. It is part of the venous thromboembolism disorders which represent the third most common cause of death from cardiovascular disease after heart attacks and stroke. Even in patients who do not get pulmonary emboli, recurrent thrombosis and "post-thrombotic syndrome" are a major cause of morbidity." (Waheed, et al., 2021).

The inpatient admission is considered partially medically necessary for this patient.                                              

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 inpatient admission is modified.