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

Diagnosis: Cellulitis and post-surgical seroma. 
Treatment: Inpatient admission. 

The insurer is denied coverage for inpatient admission. 

The denial is modified. 

This male patient has a history of hernia, gout and hypothyroidism, status-post surgery for left inguinal hernia repair. The patient was sent by his physician to the emergency department (ED) on for evaluation of surgical wound infection and fever of 104 degrees. Bloodwork showed white blood cells (WBCs) were 16.9. There was concern for sepsis and the patient was admitted to surgery for further monitoring and care. He was diagnosed with cellulitis and post-surgical seroma. Interventional Radiology and Infectious Disease specialties were consulted; the patient received intravenous (IV) antibiotics and underwent image-guided percutaneous drainage with moderate sedation. The patient was then discharged home. 

Per MCG Health Wound and Skin Care: Common Complications and Conditions, inpatient admission is necessary for clinically significant infection with vital sign abnormality or when procedure or treatment is required, such as percutaneous placement of closed-suction drains. [1] Surgical site infections complicate the course of recovery and increase postoperative morbidity and mortality. Management may include hospital admission, IV antibiotics, and sometimes surgical reintervention. [2] Early management and intervention has been shown to decrease inpatient length of stay and morbidity and mortality rate. [3, 4] The patient met criteria for initial inpatient admission due to a clinically significant infection with abnormal vital signs. However, there is no clinical documentation regarding surgical intervention and/or plans between the date of admission and the date of Interventional Radiology drainage. There is no documentation that notes the patient's wound was not improving, and that continued inpatient admission was necessary. Temperatures recorded are generally in the normal range or showed minor elevations. WBC was noted as 12.1. There is a consult note by interventional radiology with note saying "tentatively scheduled for today pending international normalized ratio (INR)". WBC was 7.2. There does not appear to be an INR in the submitted records. The INR was 1.0. The drainage yielded 60 cc of serosanguinous fluid.  The patient was discharged within 24 hours after percutaneous drainage. Although the inpatient admission was medically necessary, the length of stay is not justified based on the provided clinical notes. Based on the submitted records, it is unclear why the drainage by interventional radiology was delayed. Based on the submitted records given that it appears the drainage could have been done and discharged. Therefore, the requested inpatient stay should be modified to approve the admission, but deny the last day. 

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

The carrier's denial of coverage for the inpatient hospital admission is modified.  The medical necessity is substantiated for admission, but not the last date of service.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: sinusitis
Treatment: sinus surgery
The insurer denied sinus surgery (CPT 31298, 31295, 31254 and 30117). The health plan's determination is overturned in part.  CPT codes (31298, 31295, 31254) are indicated. CPT code 30117 is not indicated.

The patient is a female with a history of recurrent sinus infections. Per the letter from the provider, the patient had 6-7 episodes of sinusitis in a year- she has required multiple courses of antibiotics. She also failed to improve with nasal steroids, oral steroids and antihistamines. Per the office note, the patient has had a prior sinus surgery. Intranasal exam at that time showed normal nasal mucosa, narrowing of the middle meatus, inferior turbinate hypertrophy and left septal deviation.
A computed tomography (CT) of the sinuses showed diffuse mucosal thickening in the paranasal sinuses.
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: Bladder Incontinence
Treatment: Home health care (HHC) level 2 personal care services (PCS), per 15 minutes increase to 42 hours/week
The insurer denied HHC level 2 PCS, per 15 minutes increase to 42 hours/week.
The determination is overturned in part.

This is a female patient with a medical history notable for incontinence. The patient is approved for 27 hours/week of level 2 personal care services (PCS). The patient and her care team requested an increase to 42 hours/week and the request was denied by the health plan. This denial is the subject under review.

No medical records or letters of medical necessity were provided as part of this case review.

A Uniform Assessment System (UAS) was completed and was available for review. The patient's expressed goal was "I need more help with daily routine." The patient was alert and oriented to person and place. She is able to direct her own care and call for help in an emergency. For her instrumental activities of daily living (IADLs), she requires total dependence for housework. She requires maximal assistance for meal preparation and shopping. She requires extensive assistance for finances, medications, stairs, and transportation. For her activities of daily living (ADLs), she requires extensive assistance for bathing and dressing lower body. All other ADLs require limited or no assistance. She ambulates with a slow and unsteady gait due to knee pain. She is occasionally incontinent of urine and infrequently incontinent of stool. She uses pullups for incontinence care. Compared with a prior assessment, there was not a significant decline in functional status. A task tool associated with the most recent assessment recommended 33.8 hours/week to address her personal care needs, an increase from the 27 hours/week recommended on the prior assessment.


The requested health service/treatment of home health care (HHC) level 2 PCS, per 15 minutes increase to 42 hours/week has not been demonstrated to be medically necessary for this patient.

The patient requires assistance mostly with IADLs. She does require some help with bathing and dressing. The task tool can be helpful in these cases to determine an appropriate amount of personal care for the patient. In this instance, the tool is recommending 33.8 hours/week, which is greater than the 27 hours she is currently approved for.

There is no documentation regarding any unmet personal care needs, so it is not clearly demonstrated that an increase to 42 hours/week (an increase beyond the level recommended by the UAS task tool) is medically necessary at this time. However, the patient should be approved for 34 hours/week as recommended by the UAS task tool.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Prematurity Baby

Treatment: NICU (Neonatal intensive care unit) admission

The insurer denied coverage for NICU admission

The denial is modified

This case involves a newborn female who was born at 35 weeks gestation.  She was born due to her mother being induced due to preeclampsia.  She was noted to have intrauterine growth retardation (IUGR) with preeclampsia.  Documentation indicated she delivered an active and pink baby girl by normal vaginal delivery after being induced for labor due to preeclampsia/intrauterine growth retardation (IUGR).  The infant weighed 2.1 kg (kilograms) and was 44 cm (centimeters) in length.  The documentation indicated she was admitted to the intensive care unit for prematurity and impact of maternal diabetes (IDM).  The submitted documentation indicated the infant remained on room air and tolerated feedings.  She was noted to be clinically jaundiced.  At 53 hours of life, the bilirubin was 11.3.  Later that day her bilirubin was trending up to 12.5.  The following day she did remain stable, and her bilirubin had not increased.  She did undergo the car seat testing.  Throughout the entirety of the stay, there were no complications noted.  The infant remained stable and there were no adverse events.  She was discharged.

Late preterm infants are certainly at risk of hypoglycemia, jaundice, and feeding abnormalities and the testing an interventions done are appropriate. However, these did not require an intensive care unit (ICU) level of care. The infant's initial glucose checks (all normal) were not done more frequently than every 4 hours and should have been manageable in a floor setting. The infant had no indication of respiratory distress or hypothermia to prompt further monitoring. This child did not demonstrate a need for ICU-level observation or intervention. However, there are sources that recommend 12-24 hours of close observation for the mildly preterm infant, followed by rooming in with parent if stable. Therefore, the first day should be covered, while the following 2 days should be covered for floor care only.

The health plan acted reasonably in part with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an NICU is modified. Medical necessity is partially substantiated. Reverse the first day of admission and uphold the following days.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hematuria
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary, in part.

The patient is an adult male. He was admitted through the ER with gross hematuria. 

On the day of admission, the patient had gross hematuria that required admission for CBI.  However, by later in the day, the CBI was able to be discontinued.

The next day, the patient's catheter was removed.  Although he had large clots, he was medically stable and able to void spontaneously.   The primary service provided was observation for possible hematuria decompensation.  At this time, he was not in need for an acute level of care, because the same care could have been provided at a lesser degree.

The day of discharge, the patient was stable enough for discharge.  An acute level of care was not needed for this date.

Therefore, given the above, the inpatient admission was medically necessary the first night, though it was not medically necessary from the second day through the day of discharge.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  GERD.
Treatment:  Esophageal surgery and inpatient stay. 

The insurer denied the Esophageal surgery and inpatient stay.  The denial is overturned, in part. 

The patient is a male.  He is 6 feet tall and weighs 191 pounds, giving a body mass index (BMI) of 25.9 kg/m2.  He has symptomatic GERD (gastroesophageal reflux disease) despite medication use.  Manometry revealed normal esophageal peristalsis with low LES (lower esophageal sphincter) tone.  24-hour pH study revealed a significantly elevated DeMeester score consistent with GERD.  EGD (esophagogastroduodenoscopy) revealed small hiatal hernia and normal esophagus.  UGI (upper gastrointestinal series) revealed GERD to level of clavicles and normal motility. 

Specifically, the health plan should cover the Esophageal surgery.  LINX procedure standard LOS (level of service) is generally 23-hour observation or ambulatory.  Acute inpatient admission is generally not required, unless there are other high risk co-morbid conditions, such as severe CAD (coronary artery disease), or severe sleep apnea, for example, to warrant acute inpatient admission.

LINX is considered to be a standard FDA-approved surgical treatment for GERD within the medical community and is recommended in updated published guidelines from the Society of Gastrointestinal and Endoscopic Surgeons to be a safe, effective and durable treatment for GERD for mid- to long-term outcomes based on published findings.  There are only a few exclusions to the treatment, of which the patient has none.

Specifically, the Esophageal surgery is likely to be more beneficial.  The requested procedure, however, does not require acute inpatient stay and is generally performed as an outpatient/ambulatory or 23-hour observation level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: atrial fibrillation, heart disease and osteoarthritis

Treatment: home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day - split shift

The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day - split shift

The denial is Modified

 
This is an elderly female with chronic medical problems including atrial fibrillation, heart disease and osteoarthritis.  She lives with her spouse in a private residence.  The insurer approved personal care services (PCS) level 2; 35 hours/week.  The request is for home care / personal care HHC - level 2 PCS, per 15 minutes increase to 24 hours per day - split shift, denied by the insurer and leading to an external review.  

The Uniform Assessment System (UAS) report was reviewed.  The patient's cognitive skills are described as minimally impaired.  She reportedly requires extensive assistance to total dependence for performing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires extensive assistance for bathing, personal hygiene, dressing, locomotion, toilet transfer/use and ambulation.  She is reportedly at the supervision level for bed mobility and eating.   The patient is reportedly frequently incontinent of bladder and continent of bowel.  Her ability to perform activities of daily living and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days. There have been no reported falls over the prior 90 days.  The patient's cognitive status and functional ability have also declined when compared to the prior UAS report.

Based on the records reviewed, attention to the patient's functional needs are more appropriately provided and maintained by increasing PCS to 8 hours/day, 7 days/week, (56 hours/week) and shared household responsibility of other adult living in the home.  The patient may also have the option of restructuring and flexibly using the 56 PCS hours weekly to better maintain and meet her functional needs.  

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 - split shift services is not substantiated. 

However, increasing home care / personal care HHC - level 2 PCS, per 15 minutes increase to 8 hours/day, 7 days/week (total 56 hours/week) is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: sinusitis.
Treatment: sinus surgery.
The insurer denied sinus surgery (CPT 31298, 31295, 31254 and 30117). 
The health plan's determination is overturned in part.  CPT codes (31298, 31295, 31254) are indicated. CPT code 30117 is not indicated.

The patient is a female with recurrent acute sinusitis. She had 6-7 sinus infections in a year. Medical management included multiple courses of antibiotics, nasal steroids, nasal antihistamines, oral steroids, and decongestants. A CT(computed tomography) scan of the maxillary sinus showed opacification, thickening of nasofrontal ducts, ethmoid sinuses, and sphenoid sinuses. Exam revealed deviated septum, turbinate hypertrophy, and middle meatus narrowing.

The balloon sinuplasty CPT codes (31298 and 31295, 31254) are likely to be more beneficial than standard treatment because they do meet the criteria for chronic sinusitis (thickening noted on CT scan). In addition, the patient's anterior ethmoidectomy was indicated for the chronic sinus disease (noted on CT scan). Balloon sinuplasty is an option in the treatment of sinusitis that has failed appropriate medical therapy. Evidence is best for limited disease in patients with CRSsNP affecting the frontal, sphenoid, and maxillary sinuses. Because BSD can be performed in the office setting, it can be a viable therapeutic alternative in patients with comorbidities who are unable to tolerate general anesthesia.

CPT code 30117 is not likely to be more beneficial in this case. Septal swell body reduction has not been shown in well-designed, long-term studies to be an effective treatment for nasal obstruction. This procedure is not considered standard of care.
The patient had recurrent acute sinusitis refractory to medical management with CT scan evidence of sinus inflammation. Balloon sinuplasty and ethmoidectomy are considered standard of care treatment for medically refractive acute sinusitis. The patient failed medical management thus there were no reasonable medical alternatives. Balloon sinuplasty and ethmoidectomy have been shown in well-designed studies to be a safe and effective treatment for recurrent acute sinusitis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Gynecomastia
 
Treatment:  Mastectomy for gynecomastia and suction-assisted lipectomy.

The insurer denied a mastectomy for gynecomastia and suction-assisted lipectomy.  The denial was modified.

This male has lost weight following bariatric surgery and has pendulous breasts.  He complains of frequent rashes in the folds under his breasts.  According to a letter from his dermatologist, the rashes have persisted for longer than a year despite medically supervised treatment with topical and oral anti-fungal and antibiotic medications.  His surgeon recommends bilateral mastectomies for gynecomastia with liposuction.

The photos show a male with large ptosis breasts and rashes in the inframammary folds.  The medical treatments for his rashes have failed.  The most appropriate next treatment is mastectomy for gynecomastia to remove the excess breast skin and fat that creates the folds under which moisture accumulates, leading to rashes.  There is no other treatment that is likely to cure his chronic rashes.

Liposuction is a cosmetic body contouring procedure that does not confer any health benefit.  The liposuction removes fat to improve appearance and is a cosmetic procedure.  The records do not document any health problems that will be improved with liposuction treatment. 

The carrier's denial of coverage for CPT code 19300-50 Mastectomy for gynecomastia and CPT code 15877-50 Suction-assisted lipectomy- trunk is modified.  Approve CPT code 19300-50 Mastectomy for gynecomastia.  Deny CPT code 15877-50 Suction-assisted lipectomy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia

Treatment: Personal Care Aide (PCA): 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week 

The insurer denied coverage for PCA: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week

The denial is modified

This is an elderly patient with progressive Alzheimer's dementia. The patient lives with his spouse in a 2-bedroom apartment. The insurer approved PCA 4.5 hours/day, 7 days/week (31.5 hours/week). He is requesting 24 hours/day,7 days/week (split shift).  

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Moderately Impaired- Decisions consistently poor or unsafe; cues/supervision required at all times." The patient requires extensive assistance for bathing, personal hygiene, and lower body dressing. Limited assistance is needed for upper body dressing and toilet transfer. He is occasionally incontinent of bladder and continent of bowel. Supervision is needed for eating; toilet use and ambulation. The patient is independent with bed mobility. His functional ability has declined compared to the prior UAS report, particularly for cognition, bathing, and hygiene and lower body dressing. The insurer's PCA increase from 4 to 4.5 hours/week is inadequate to meet his functional needs. However, the patient's condition and functional decline are not at a level or unpredictable as to require the requested PCA services 24 hours/day, 7 days/week (split shift). Safety monitoring under personal care services does not include monitoring an individual (e.g., dementia) when no other Level I or Level II personal care services task is being provided. Based on the records reviewed, the patient's health and safety would be more appropriately provided and maintained at home by increasing PCA services to 12 hours/day, 7 days/week (total 84 hours/week).

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.  

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 insurer's denial of coverage for personal care aide (PCA): 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week is modified as noted above. Medical necessity is not substantiated for 12 hour per day 7 days a week (split shifts) for total of 168 hours weekly. However, 12 hours per day 7 days a week is medically necessary.