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

Diagnosis: Osteoarthritis, secondary malignant neoplasm of the bone, age-related physical debility
Treatment: Personal Care Aide (PCA), 24 hours/day, 7 days/week
The insurer denied coverage for PCA, 24 hours/day, 7 days/week.
The denial is overturned, in part.

The patient is an elderly male who lives with his spouse in a 1-bedroom apartment on the 5th floor. The patient is diagnosed with primary generalized osteoarthritis, secondary malignant neoplasm of the bone, age-related physical debility, decline, muscle weakness generalized, abnormalities of gait and ability, essential tremors, personal history malignant neoplasm of the prostate, personal history of antineoplastic chemotherapy, presence of other vascular implants and grafts, presence of cardiac pacemaker, coronary artery disease (CAD), hypertension (HTN), dizziness, fatigue, chronic pain, hearing loss and deficits of endurance, physical mobility, and ability to carry out activities of daily living (ADLs). Due to his overall health condition, the patient requires assistance with bathing, cleaning, shopping, laundry, cooking, and with all household chores. According to the comprehensive community health assessment, the participant needs help with meal preparation, housework, bathing, personal hygiene, dressing upper and lower body, walking, locomotion, toilet transfer, medication, and bed mobility. The patient had a recent fall, sustained a broken hip, and underwent surgery and inpatient rehabilitation. On the day of discharge home, he suffered another fall, injuring the left knee. 

The patient can no longer independently perform ADLs. The patient needs assistance with meals and medication, repositioning bi-hourly to prevent pressure ulcers. The appeal requested 2 split shifts of 12 hours daily, 7 days/week for the participant. 

The plan partial approval was for 10 hours/day, 7 days/week.

Based on the assessment and clinical documentation, the participant's needs can be sufficiently provided with 91 hours/week live-in. As per the documentation, due to significant decline in physical ability and recent injuries he needs support in all ADLs. 

The approved 10 hours/day, 7 days/week is not sufficient to support the participant's required care needs and maintain safety within his community. As such, the request Is modified to provide 91 hours/week live-in.

Based on the above, the insurer's denial must be overturned, in part. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The medical necessity for Personal Care Aide, 24 hours/day, 7 days/week services is not substantiated. However, 91 hours/week live-in is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Abuse
Treatment: Inpatient Hospital Admission for Detoxification Treatment

Summary: This patient was admitted to inpatient hospital treatment due to alcohol withdrawal. He had withdrawal symptoms including nausea and vomiting 5-6 times, elevated heart rate of 99 and elevated blood pressure of 165/102, agitation, tremors, tongue fasciculation, weakness, diaphoresis, and he had poor oral intake. He was drinking 2/5 of vodka per day. He reportedly had multiple past inpatient detoxification treatments. He had a medical history significant for deep vein thrombosis, dehydration, sleep apnea, back pain, and alcohol cirrhosis, and also had reports of depression and anxiety. He had a past suicide attempt. He reportedly took Librium and had intravenous Versed, normal saline, thiamine, and folate. He had deconditioning and weakness.
 
The insurer denied coverage for the inpatient hospital treatment for detoxification treatment as not medically necessary. The denial was modified.

The denial was partially approved because he did require 24 hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use alcohol after inpatient detoxification treatments and he needed detoxification medications to modify withdrawal. Chart notes reported that he still had alcohol withdrawal symptoms and a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) of 5 and required and took Librium for withdrawal. He still had withdrawal symptoms including diaphoresis, flushed face, tongue fasciculation, and anxiety.  There was reported excessive sweating, anxiety, and unsteady gait. He needed 24 hour treatment as he was at high risk for worsened withdrawal symptoms including life threatening withdrawal symptoms if not in this 24 hour setting at that time. The subsequent days of the admission were denied because there were no reports of withdrawal or detoxification medication. Notes reported that he had no acute events, that the alcohol withdrawal resolved, and he no longer required detoxification medication.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia
Treatment: Personal Care Aide (PCA) Services: Total Amount of 168 Hours per Week (Split-Shift) 
The insurer denied Personal Care Aide (PCA) Services: Total Amount of 168 Hours per Week (Split-Shift) 
The health plan's determination is overturned in part. Personal Care Aide (PCA) Services 12 hours per day, 7 days per week for a total of 84 hours per week is medically necessary for this patient.

The patient is a female with medical history notable for Alzheimer's dementia, unsteady gait, and recurrent falls. 

The requested health service of Personal Care Aide (PCA) Services: Total Amount of 168 Hours per Week (Split-Shift) is not medically necessary for this patient.
Personal Care Aide (PCA) Services 12 hours per day, 7 days per week for a total of 84 hours per week is medically necessary for this patient.
The documentation provided in the letters and the Uniform Assessment System (UAS) demonstrate that the patient requires personal care assistance for essentially all activities of daily living, including toileting, transfers, and ambulation. Her provider requests additional hours to help with her needs as well, specifically requesting 12 hours per day. This is a reasonable amount of hours to request, given that she requires extensive assistance for most activities of daily living. 12 hours per day will allow a caregiver to be present during most waking hours of the day to address her needs.
There is insufficient documentation provided regarding which personal care needs that she would need addressed overnight or why she would require split-shift personal care. Split-shift personal care aides are used for care needs which are continuous and unscheduled throughout the night, such as turning and repositioning to treat a pressure ulcer. There is no documentation providing regarding if there are any unmet overnight care needs. Therefore, the requested increase to split shift care has not been demonstrated to be medically necessary. An increase to 12 hours per day of personal care assistance is medically necessary and reasonable for the patient.
Appeal type: Medical necessity
Decision: Overturned

Depression
Mental Health: Inpatient

The patient is a male with diagnoses of Major Depressive Disorder (MDD), severe, recurrent, without psychotic features, Cannabis Use Disorder (CUD) and a pain syndrome. Case notes document that the patient has suffered from depressive symptoms for about three years, with acute exacerbation about 6 months prior to the admission in question due to a motor vehicle accident (MVA). In addition, the patient has experienced pain in his back and headaches from the MVA. He has experienced anhedonia, anxiety, poor sleep, anorexia, and decreased energy, as well as suicidal ideation with a plan. He self-discontinued his outpatient medications several months before this admission.

The health plan's determination is overturned in part. An additional three days of inpatient mental health treatment was medically necessary. His MDD was complicated by his co-morbid substance use disorder and his pain syndrome, making his MDD more difficult to treat. He had a suicide plan. His illness was chronic and severe. Case notes document that he was isolative, with flashes of negative thoughts, not interacting with peers, with diminished appetite. His attending noted continuing depressive and anxiety symptoms. He rated his anxiety as 6/10. The patient felt anxious about moving to outpatient treatment. He continued to be anxious despite some improvement in depression. He had fleeting death thoughts. He was not back to a baseline mood state. Eventually, he had no suicidal ideation, was not hopeless or helpless, was low in anxiety, with improved sleep, with euthymic affect and good behavioral self-control. Therefore, he could safely and with good judgment be discharged on the 3rd day in question to a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, congestive heart failure and chronic kidney disease

Treatment:  7 day x 24 hour split shift (2x12) PCA service (168 hours per week)

The insurer denied coverage for 7 day x 24 hour split shift (2x12) PCA service (168 hours per week)

The denial is modified.

This is a male patient with Parkinson's disease, congestive heart failure and chronic kidney disease.  According to the case notes, the plan approved 7 days x (times) 5 hours of personal care assistant  (PCA) service (35 hours/week).  The plan approved 7 days x 6 hours of PCA service (42 hours/week).  Under review is the medical necessity for requested 7 days x 24-hour split shift (2x12) for PCA service (168 hours/week).

According to the Uniform Assessment System (UAS) report, the patient's cognitive ability is described as "minimally impaired."  He can "verbalize daily care needs and direct his care."  He is also "able to verbalize emergency plan to call 911" and "use programmed phone to call daughter."  The patient requires extensive assistance for lower body dressing; otherwise, he requires only limited assistance for bathing, personal hygiene and toilet use/transfer.  He is occasionally incontinent of bladder and completely continent of bowel.  The patient's cognitive and functional impairments do not support the medical necessity of the requested 7 days x 24-hour split shift (2x12) for PCA service (168 hours/week).  However, increasing PCA service to 7 days x 10 hours (70 hours/week) is clinically appropriate and medically necessary to allow the patient to continue living safely at home.   

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  (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).  

From a physical medicine and rehabilitation perspective, coverage for 7 days x 24-hour split shift (2x12) for personal care assistance service (168 hours/week) is not medically necessary.  However, increasing PCA services to 7 days x 10 hours (70 hours/week) is clinically appropriate and 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 a 7 day x 24 hour split shift (2x12) for personal care assistance service (168 hours per week) is modified. Medical Necessity is substantiated for PCA service for 7 days x 10 hours (70 hours/week).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal
Treatment: Inpatient hospital stay

Diagnosis: Orthopedic/Musculoskeletal-Hip problem/Pain.
Treatment: Inpatient hospital stay.
The health plan denied the entire inpatient hospital stay as not medically necessary.
The reviewer has overturned in part the health plan's determination. 

This is a patient who was diagnosed with right hip arthritis. The patient is noted have comorbidities of morbid obesity status post gastric bypass,  lymphedema of both lower extremities, asthma, chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), hypertension, sleep apnea, and a history of deep vein thrombosis (DVT). A preoperative medical evaluation documents that the patient has had 8 years of pain and requires hip arthroplasty. The patient has a history of DVT and utilized Xarelto for 3 years in the past. An operative note documents that the patient underwent a right total hip replacement computer assisted navigation. A wound vacuum was placed. A progress note on the second Post operative day documented surgical site pain necessitating subcutaneous Dilaudid. The provider recommended ongoing discharge planning, DVT prophylaxis, and pain management. An orthopedic note the next day documented that pain was controlled overnight and the provider recommended discharge planning, pain control, DVT prophylaxis. Transfer to acute rehabilitation was denied. The patient refused subacute rehabilitation. The patient continued skilled physical therapy (PT) to increase stability and endurance with stair negotiation, and continued to decline subacute. The patient was eventually discharged home with home health. 

The requested inpatient stay would be medically necessary in part. The documentation provided indicates that the patient underwent right total hip arthroplasty and has significant comorbidities. The patient had an uneventful postoperative course and participated with physical therapy and was stable for discharge to rehabilitation 2 days later, which was denied. The patient remained inpatient for ongoing physical therapy services and discharged home with home health several days later. Given the significant comorbidities inpatient care would be medically necessary until the patient was ready for discharge to a lower level of service such as the recommended rehabilitation.
The Milliman Care Guidelines(MCG) criteria state that most patients are inpatient status after hip arthroplasty. The MCG criteria indicate outpatient arthroplasty is supported when there are no comorbidities that increase risk or require more than 24 hours of postoperative monitoring. A goal length of stay is 2 days. The documentation provided indicates that the patient has significant comorbidities of sleep apnea, morbid obesity, lymphedema, COPD, hypertension, and history of DVT. This would preclude outpatient arthroplasty and given the history of sleep apnea and need for opioid medication to control pain for more than 24 hours, postoperative monitoring would be indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left hip osteoarthritis
Treatment: Outpatient Surgery (20985 x1, 27160 x 1)
The insurer denied coverage for Outpatient Surgery (20985 x1, 27160 x 1)
The denial is modified 

According to the documentation submitted, this is a patient with a history of left hip osteoarthritis, chronic pain, post-traumatic stress disorder, anxiety and asthma. The patient had a physician's office visit for left hip pain. The note stated that the patient had less than a 10-minute standing and walking tolerance and had to utilize a cane to assist with ambulation. The patient had previously undergone hip arthroscopy which failed at giving the patient pain relief. At that time the patient was found to have significant osteoarthritis. The patient noted no improvement and still had significant limitations as a result of the left hip pain. 

The insurer has denied coverage for Outpatient Surgery (20985 x1, 27160 x 1) as not medically necessary. In their Final Adverse Determination letter they write that the patient asked for a total left hip replacement, to approve this service, the following criteria must be met: criteria from the turning point guidelines named "Total Hip Replacement (OR-1001)", "computer assisted navigation (OR-1035), and "Medical record documentation (GN-1002)". Based on the information provided, these criteria are not met.

The medical records were consistent to confirm a pain generator. There is presence of pathology localized to the left hip joint. Subjective complaints and objective findings confirm the progressive deterioration to her hip joint. Imaging studies using magnetic resonance imaging (MRI) and X ray show joint pathology. The patient has received several treatments which were not effective; that is, arthroscopy, medications and physical therapy. The records showed she attempted but could not tolerate the service. She had also undergone bariatric surgery. She was counseled by her physician about additional weight loss. She was counseled and reported not smoking. 

The use of the computer navigation (20985 X1) in performing the operation is not essential. Placement of components are improved but no evidence for long term outcome has been reported. 

In conclusion, the total hip replacement (27160 X1) would be necessary. The use of computer navigation would not.

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 denial of the computer navigation (20985 X1) is upheld. The medical necessity for Outpatient Surgery (27160 x 1) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Traumatic Brain Injury

Treatment: 21 Meals/Week, 3 Meals x 7 days; Home Delivered Meals

The insurer denied coverage for 21 Meals/Week, 3 Meals x 7 days; Home Delivered Meals.

The denial is modified.

 
This case involves an adult female who lives with her caregiver who provides emotional support and care with a subject of review for the coverage of 21 Meals/Week, 3 Meals x 7 days; Home Delivered Meals. She has a history of intervertebral disc displacement of the lumbar spine, bipolar disorder, anxiety, depression, hypertension, post-traumatic stress disorder (PTSD), pain, and limited range of motion. 

In the Letter of Medical Necessity, the patient is reported to have suffered from a traumatic brain injury from vehicular accident that resulted in hospital stay with fractures to her cervical and thoracic spine, sustained laceration to her liver and spleen and had resection of her colon. She is unable to prepare meals herself due to safety reasons. She does have a home health aide at her home until 1:00 pm. Due to her condition she is not always able to eat while the aide is present. 

The medical records provided for review do support the service being requested. It would be proper and reasonable for her to receive home delivered meals to cover at least two meals each day, in order to guarantee that there are always cooked meals when her aide leaves at 1:00 PM. As a result, the assessment does support the request for home delivery of 2 meals a day seven days a 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 21 Meals/Week, 3 Meals x 7 days; Home Delivered Meals services is not substantiated. However, the assessment does support the request for home delivery of 2 meals a day seven days a week.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Prosthetics. 

The insurer denied passive prosthesis and glove. 
The denial is overturned in part. 

The patient is a male with congenital left-hand amputation. He currently uses a myoelectric prosthesis for activities of daily living (ADL). He is in need of a new passive prosthesis since he cannot use powered prosthesis on the Sabbath. 

The health plan's determination is overturned in part. 

The requested passive left arm prosthesis is medically necessary for ADL assistance and is standard of care to provide this for congenital amputee. The silicone glove is not medically necessary. The silicone glove does provide increased durability and benefits for a pediatric patient which can help with self-esteem and acceptance of the prosthesis by the patient and peers, however, this component is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pregnancy/Childbirth/Other-NAS
Treatment: Inpatient hospital stay
The health plan denied the extended stay in the hospital for this patient. 
The reviewer has overturned in part the health plan determination.

The infant was born by vaginal delivery. The neonate was 40.1 weeks estimated gestational age and her mother was a  Gravida 6 now Para 2  who had late prenatal care. Maternal serologies were negative, and the medical history was significant for chlamydia that was treated and oxycodone use. The mother had prescribed use of oxycodone for sciatica, and was taking 10-30 mg/day. Drug testing on the mother was positive for oxycodone only.
The infant's birthweight was 3365 grams, and the Apgar scores were 9 and 9 at one and five minutes, respectively. The neonate was taken to the Neonatal Intensive Care Unit (NICU) for observation related to neonatal withdrawal. A urine drug screen on the neonate was positive for oxycodone and methamphetamines. Social work contacted Child Protective Services (CPS).
The neonate was hemodynamically stable, breathing unassisted room air and able to orally feed. The neonate had some emesis and then tolerated the formula, Gentlease. The infant was noted to have a normal neurologic exam and experienced minimal withdrawal. Finnegan Scores were noted to be lower than those requiring medical treatment. A repeat urine drug screen was obtained on the neonate and was pending on prior to discharge. The neonate was cleared for discharge to the mother, and the only symptoms of neonatal drug withdrawal were mild tremors. The neonate was discharged to the care of the mother with CPS following up after discharge.
The requested health service/treatment of Inpatient Hospital Admission was not medically necessary for this patient, in part. NICU level of care was not medically necessary, however an additional day in the hospital at a lower level of care prior to discharge would have been reasonable.

The neonate was in the hospital for signs of Neonatal Abstinence Syndrome (NAS). She was able to orally feed, was breathing unassisted room air, and had minimal signs consistent with NAS. However, the infant's Finnegan Scores (FS) increased to 7. Threshold for treatment of NAS in most protocols is 3 consecutive FS greater than or equal to 8. Although the patient still did not meet criteria for medical treatment of her NAS, with the FS increasing to 7, it would have been reasonable to allow one additional day in the hospital at a lower level of care prior to discharge.

The neonate was 7 days old and had not met criteria for medical treatment. Although neonates may exhibit withdrawal for up to two weeks after birth, the appropriate period of observation in the hospital depends upon the recent maternal drug use. In this case, the infant's urine drug screen was positive for oxycodone and methamphetamine. The exact dose and duration and type of maternal narcotic use was not clear in the medical record (mother was only positive for oxycodone). Therefore, the documentation presented supports the extension of the hospital stay at a lower level of care.