Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gender Dysphoria
Treatment: surgical services
The insurer denied Application of Skin Substitute with Use of Operating Microscope
The health plan's determination is overturned in part. 

This patient is to undergo radial forearm flap phalloplasty for treatment of gender dysphoria. The surgeon plans the use of Integra to cover the donor site on the arm.

The Application of Skin Substitute is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The Use of Operating Microscope is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Multiple studies support lessened donor site morbidity and improved functional and aesthetic outcomes when radial forearm free flap donor site is covered with Integra. According to Murray et al: " Composite reconstruction with Integra artificial dermis offers advantages over traditional methods of coverage for select cases of radial forearm free flap donor site closures." According to Gravvanis et al: 'In conclusion, suprafascial dissection of the forearm flap creates a superior graft recipient site, and the use of Integra artificial dermis is a valuable advancement to further minimize the donor-site morbidity, resulting in excellent functional and aesthetic outcomes."
Finally, according to Adani et al: "Favorable cosmetic and functional outcomes were obtained using a dermal regeneration template for the treatment of donor site defects. Despite the drawback of an additional surgical procedure (secondary skin graft), the use of this artificial skin produced soft-tissue augmentation and graft-skin quality, reducing donor site morbidity." Per Wirthman et al: " Long-term results show an esthetic and functional successful defect coverage of the RFF donor site by the use of Integra and split-thickness skin. "
Integra is medically necessary to cover the radial forearm donor site. A microscope is not required. Integra can be placed without a microscope.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with multiple medical problems, most notably weakness secondary to a previous stroke, along with gait dysfunction, urinary incontinence and generalized medical deconditioning.
Personal care services 24 hours a day live in, 7 days per week, 91 hours total per week were requested and denied based upon medical necessity. At issue is the medical necessity of personal care services 24 hours a day live in, 7 days per week, 91 hours total per week.
The health plan's determination is overturned in part. Although live in services are not medically necessary, according to the information provided the patient requires more care than can be met with 60 hours a week of care. Increasing the services to 12 hours a day 7 days a week is indicated.
The health plan noted the following in regard to the denial. The patient needs help with preparing meals, housekeeping, laundry, shopping, dressing, bathing, toileting, medication management and personal hygiene. She is noted to have intermittent bladder and bowel incontinence. Her daughter manages her medications. Giving more hours to have someone in your home will not stop falls or accidents. Giving more hours to have someone in your home would be for safety and supervision and the plan is not required to provide services for this alone. Also hours for companionship is not medically necessary when the tasks are being provided.
Additional service hours for nocturnal care are not medically necessary. There is no notation that the patient has any complex medical condition which would require frequent care during the middle the night such as turning or repositioning. No wound ulcers or other conditions are noted in the medical chart. An evaluation in August, nursing visit, showed no pressure sores. A physician statement  states that the patient now developed pressure sores. There is no specific other documentation provided in regards to this.  There are no specific orders such as orders for frequent repositioning to be performed at night.  There are no other treatment orders in regards to the new pressure sores.
The Uniform Assessment System (UAS) State of New York, HELPS tool was provided and used to calculate activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The assessment noted the patient required more care for a total of 12 hours a day 7 days a week or 84 hours a week. Currently, the patient is receiving 60 hours a week. Additional service hours, as per the above rationale, are noted to be medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental disease
Treatment: Dental services

The patient is a female with congenital medical condition causing loss of teeth. The request is for 3-unit implant supported bridge, teeth 3-5, as well as crowns on teeth 6 and 7.

The Dental services are medically necessary, in part.

Specifically, the implants for 3 and 5, as well as bridge that attaches to them are medically necessary. The need for these specific services is due to the loss of these teeth due to the patient's genetic disorder. Therefore, they are medically necessary. The request for crowns on teeth 6 and 7 are not medically necessary and are not due to the patient's medical condition. Teeth 6 and 7 are existing, sound teeth that need crowns, but not because of the genetic condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Shortness of breath, tachypnea, elevated blood pressure
Treatment:  Inpatient admission
The insurer denied the inpatient admission.  The denial is overturned in part.

The patient is a homeless female with diabetes, hypertension, advanced kidney disease.  She presented to the hospital with shortness of breath, tachypnea and elevated blood pressure (BP). 

The patient was treated with intravenous diuretics and antibiotics.  She was evaluated by the nephrology team for advanced renal dysfunction and volume overload.  With advanced renal dysfunction and volume overload, plan was in place for initiation of hemodialysis.  The patient had a tunneled hemodialysis catheter placed and was initiated with dialysis treatment #1 and treatment #2.  The patient was discharged with a dialysis facility in place. 

During the end dates of service the patient was on maintenance hemodialysis M/W/F, Venofer and erythropoietin stimulating agent for anemia with optimization of oral antihypertensives for BP controlled and planned for fistula placement.

The Inpatient admission was medically necessary, in part.

Based on the available data, in the beginning, the patient did have uremic symptoms that were severe or persisted despite observation care treatment, significant respiratory findings that were severe or persistent, hypertension requiring inpatient care, as well as urgent treatment of renal failure (e.g., dialysis) necessary on inpatient basis, including placement of tunneled dialysis catheter and initiation of dialysis.  The patient required a permanent access and establishing ESRD (end stage renal disease) status prior to being clinically stable for discharge. 

However, for the end dates of service, continued inpatient admission was not medically necessary, as there were no cardiac arrhythmias of immediate concern, recurrent seizures, encephalopathy, impaired hemostasis, severe infection, unexplained syncope, hemodynamic instability, uremic symptoms that are severe or persist, significant metabolic or electrolyte abnormalities, hypertension requiring inpatient care, urgent treatment of renal failure (e.g., dialysis) necessary on inpatient basis. 

For the beginning dates of service, the patient required inpatient care to establish ESRD and initiate dialysis for volume and advanced kidney disease.  For the end dates of service, maintenance of hemodialysis, fistula planning and optimization of oral anti-hypertensive therapy did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sleep apnea.
Treatment: Continued rental of Bi-Level Positive Airway Pressure Device With Heated Humidifier (procedure codes E0470 and E0562).
The insurer denied the Continued rental of Bi-Level Positive Airway Pressure Device With Heated Humidifier (procedure codes E0470 and E0562).
The denial is partially overturned.

The patient is a male with Duchenne Muscular Dystrophy with sleep apnea and respiratory failure associated with his neuromuscular condition. His AHI (apnea hypopnea index) is 29. He does not show CO2 (carbon dioxide) retention.  He has been prescribed BiPAP (bi-level positive airway pressure) after Titration suggested better efficacy than CPAP (continuous positive airway pressure). On receipt of the machine in February, the patient reported problems of mask fit.

In review of the patient's compliance data, there is progression in use, but not achievement of 4 hours for 70% of nights at the end of monitoring. When used, the patient does demonstrate improvement in baseline AHI (apnea hypopnea index).

Yes, in part. The Continued rental of Bi-Level Positive Airway Pressure Device With Heated Humidifier (procedure codes E0470 and E0562) is medically necessary, in part.
Given the patient's underlying medical condition with anticipated progression of disease and consequent respiratory insufficiency, a new 90-days trial of the BiPAP (bi-level positive airway pressure) device is medically necessary for this patient.

The plan appropriately followed its policy for continuation of therapy based on compliance, but this patient's medical condition necessitates another trial period in the interest of the patient's health.  A new 90 day trial should be authorized, and the provider encouraged to closely monitor usage by the patient to achieve the greatest potential benefit from the medical device.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right groin abscess
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is overturned in part.


The patient presented to the emergency department (ED) with right groin swelling and pain of 2-days duration. Her past medical history is notable for coronary artery disease, schizophrenia, hypertension, and diabetes. At the time of presentation, there was swelling of the right groin. She was without a fever though her heart rate was elevated (113 beats/minute). Imaging (a computed tomography (CT) scan) did identify an abscess of the right groin. She was admitted to the hospital.
The white blood cell count (WBC) count was elevated at 20.3 thousand (K). Surgical consultation was obtained. She was treated with intravenous (IV) antibiotics and surgical drainage of the abscess. Her temperature was normal, the heart rate was 102 beats/minute and her other vital signs were normal. The WBC was down to 15 K. Serum electrolytes identified a slightly low corrected sodium value. The glucose level was elevated at 371. She was treated for hyponatremia and diabetes. She received IV antibiotics. The pain was controlled and she was started on a diet.
The next day, the WBC was down to 11.5 K and the sodium value was 130. The glucose was normalized to 126. A psychiatric consultation was requested for her diagnosis of schizophrenia. She was receiving IV antibiotics (Vancomycin and Cefoxitin). The WBC count was normal at 9.2 K. The sodium was up to 132 and glucose was 219. Pain was controlled with oral medications. The infectious disease consultant recommended oral antibiotics. The treatment plan included discharge to a skilled nursing facility for wound care. The patient received daily wound care and was considered to be stable for discharge from the hospital to her home. She was provided ongoing oral antibiotics and instructions for wound care.
At issue is the medical necessity of an inpatient stay.

Yes, the services were medically necessary in part. The records do support that there were acute clinical issues that mandated an inpatient stay for 5 days. The patient presented and was admitted to the hospital  with a right groin abscess. 
She required urgent surgical intervention which was performed, provision of IV antibiotics, post-surgical wound care, coordination of care with infectious disease, surgery and psychiatry, and treatment of hyponatremia and diabetes. However, as of the sixth day, the patient was clinically stable with normalization of the WBC count and the antibiotics were converted to oral delivery.  Her clinical needs could have appropriately been managed at a lower level of care as of that time.

The care provided was most appropriately rendered in the inpatient setting for the first 5 days. However, the care provided after that could have reasonably been rendered at a lower level of care and did not require continued inpatient care. The patient was clinically stable with a normalized WBC count, normal vital signs and she was converted to oral antibiotics based on the recommendations of the infectious disease service.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental treatment

Treatment: Crowns (D2750) on tooth #s 5, 18, 19 & 31

The insurer denied coverage for Crowns (D2750) on tooth #s 5, 18, 19 & 31.

The denial is modified.

Upon review of the submitted documentation which includes narrative letter and multiple periapical radiographs, and copies of panoramic radiographs, dental charting and treatment notes, intraoral photograph and photographs of broken dental restoration, and insurer correspondence, it appears that this patient presented to the dentist for evaluation and comprehensive dental treatment. Based on the documentation full coverage crowns were recommended for teeth numbers 5, 18, 19 and 31 due to sensitivity and prior endodontic treatment on tooth number 18. The insurer has denied the services stating that these services are not medically necessary treatment as the clinical documentation does not support the requested services and does not meet required clinical criteria. 

Based on the submitted objective information for review, the radiographic documentation does not support the dental treatment on teeth number 5, 19 and 31 recommended by the dentist. It appears that there is no evidence of fracture or other pathology specifically affecting numbers 5, 19 or 31 based on the images provided for review. There does not appear to be any radiographic evidence of caries. The radiographs do not substantiate the requested full coverage crowns for teeth numbers 5, 19 and 31. As the documentation is inadequate to support the treatment, these services are considered not medically necessary. 

As regards number 18 this tooth has already undergone endodontic therapy with placement of a temporary restoration. This tooth will have adequate residual coronal structure for support of post and core and crown and adequate residual periodontal alveolar bone height. The standard of care in general dental practice after endodontic therapy is a full coverage crown restoration which would have an excellent long-term prognosis with the recommended treatment.

Uphold denial for crowns (02750) on tooth numbers 5, 19 and 31 as the provided documentation for review is inadequate and did not support the treatment recommended. 

Reverse denial for crown (D2750) on tooth number 18 and approve as medically necessary as the clinical and radiographic documentation support this service, and this service would be a standard of care in general dental practice.

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 Crowns (D2750) on tooth numbers 5, 19 & 31 services is not substantiated. However, crown for tooth number 18 is supported.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alzheimer's disease, heart disease, hyperlipidemia, arthritis, and gait abnormality.
Treatment:  Consumer Directed Personal Assistance Services (CDPAS) 24 hours a day, 7 days a week (split shift).

The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS) 24 hours a day, 7 days a week (split shift).  The denial is modified.
 
This is an elderly patient with heart disease, arthritis and Alzheimer's disease. She lives with relatives, including a grandniece, who directs her care. The insurer approved Consumer Directed Personal Assistance Services (CDPAS) 63 hours/week, and the request is for CDPAS, 24 hours/day, 7 days/week, (split shift).

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition was described as "severely impaired." She is totally dependent for most of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She requires maximal assistance for bathing, dressing and toilet use. Extensive assistance is needed for eating and toilet transfer. She is frequently incontinent of bowel and bladder. Only limited assistance is needed for mobility (bed mobility, locomotion and ambulation). The patient's condition and functional needs are not at a level or unpredictable as to require the requested CDPAS 24 hours/day, 7 days/week (split shift). Based on the records reviewed, the patient's health and safety can be more appropriately provided and maintained at home with an increase CDPAS 12 hours/day, 7 days/week (84 hours/week). This physician does note the patient's condition had deteriorated over the prior 90 days, "due to further cognitive decline, worsened agitation and wandering." This physician would also agree that the patient may require additional monitoring for safety and companionship; particularly due to her agitation, wandering and attempts to leave the residence. However, safety monitoring under PCS (personal care services) does not include monitoring an individual (with dementia) when no other Level I or Level II personal care services task is being provided.  

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 consumer directed personal assistance services (CDPAS) 24 hours a day, 7 days a week (split shift) services is not substantiated. However, increasing CDPAS to 12 hours/day, 7 days/week (84 hours total) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal stenosis, osteoporosis status compression fractures and right eye macular degeneration

Treatment increase in Personal Care Aide (PCA) Level 2 hours to 12 hours per day, 7 days per week (split shift)- for a total of 168 hours per week 

The insurer denied coverage for increase in PCA Level 2 hours to 12 hours per day, 7 days per week (split shift)- for a total of 168

The denial is modified

This is a patient with spinal stenosis, osteoporosis status compression fractures and right eye macular degeneration. She lives alone in a 4-bedroom house.
The patient requires extensive assistance for activities of daily including bathing, lower body dressing and toilet use. She requires limited assistance for personal hygiene, upper body dressing and walking in home. Cognition is reported as moderately impaired.  She is frequently incontinent of bladder and infrequently incontinent of bowel.  

The office visit notes from the patient primary care physician were also reviewed. The patient was seen by her primary care physician, feeling well without complaint. Musculoskeletal Review of Systems was documented as negative for arthralgias, myalgias and neck stiffness. Psychiatric/Behavioral Review of Systems was documented as negative for confusion and decreased concentration. She was in no acute distress and described as alert and oriented to person, place, and time. There were no focal (neurological) deficits present.   

Review of the Uniform Assessment System (UAS) combined with primary care physician office visit notes do not support cognitive and functional impairments that support the requested PCA level 2 services- a total of 168 hours per week. However, the records do support an overall decline; particularly her cognitive status and to a lesser extent her functional status. PCA Services Level 2; of 12 hours per day, 7 days per week for a total of 84 hours per week is medically necessary. The increased PCA services will allow the patient to continue living safely at home.   

The health care acted reasonably in part.

The requested PCA level 2 services, 12 hours per day- 7 days a week; 12 hours per day- 7 days a week (split shift) - for a total of 168 hours per week, is not considered medically necessary for this patient. However, increasing PCA services to level 2; 12 hours per day, 7 days per week for a total of 84 hours per week is medically necessary.  

The insurer's denial of coverage for personal care aide (PCA) level 2 services, 12 hours per day- 7 days a week; 12 hours per day- 7 days a week (split shift)- a total of 168 hours per week is modified as noted above.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe headache
Treatment: Inpatient stay
The insurer denied Inpatient stay.
The denial is Partially overturned

The patient is a male who presented to the hospital due to a severe headache along with fatigue and fever for ten days. Motrin had not been helpful for his headache. The patient reported a recent trip to Mexico during which he was bitten by a mosquito. Following the trip, the patient and his wife had gastroenteritis, which improved with antibiotics, but the patient then began having headaches.  The patient had been seen previously in the emergency department the week prior, at which time he refused to undergo a computed tomography (CT) scan or lumbar puncture but his fever improved with intravenous (IV) medication. Due to the duration of his headache, the patient's primary care physician recommended the patient return to emergency department to undergo a CT scan. 

The patient had symptoms of intracranial infection including nuchal rigidity, altered sensorium, fever and un-resolving headaches. Structural lesions and increased intracranial pressure were ruled out but the patient was diagnosed with viral encephalitis. Considering this diagnosis, the patient was treated with antiviral medications and antibacterial medications until the cultures came back clear and PCR for the most severe and most treatable type of viral encephalitis, namely herpes, came back negative. Additionally, the patient had severe symptoms. Therefore, admission for the first three days were justified and medically necessary for appropriate diagnostic workup, intravenous therapies, imaging, spinal tap, and intravenous medications.

However, the last two admission days were not medically necessary. The patient's cerebrospinal fluid tests were normal, symptoms of encephalitis have resolved, and the patient had post spinal tap headaches, a condition which can be typically managed with maintaining horizontal body position for 24 to 48 hours, as well as oral analgesics and oral caffeine. These interventions are commonly done on an outpatient basis. There was no need in the hospital admission for the management of post-spinal tap headaches and therefore the last two admission days were not medically necessary.