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

Diagnosis: Suicide attempt, hallucinations.

Treatment: Inpatient admission, evaluation, and medication management

The insurer has denied inpatient mental health. That denial was modified.

The patient was admitted to inpatient mental health treatment due to a suicide attempt by overdose of Mirtazapine. She had reports of command auditory hallucinations suicidal in nature, persecutory delusional thinking, depressed mood, feelings of hopelessness, helplessness, and worthlessness, psychomotor retardation, irritable mood, poor activities of daily living (ADLs), and she had a past reported suicide attempt. She was initially admitted to telemetry after the suicide attempt.  She had diagnoses of Schizoaffective Disorder and Major Depressive Disorder.  She took Abilify.

The insurer denied coverage for continued inpatient mental health treatment in this hospital as not medically necessary.  They stated that she was stable with no self-harm or suicidal thoughts, had no mention of active psychiatric issues, was responsive to treatment, and they recommended a less restrictive level of care.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with past suicide attempts are at high risk for suicide and past suicide attempts are the single most reliable indicator of suicide.  It also states that patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital.  This patient was considered a high risk patient and required continued inpatient acute hospital treatment in the hospital as she had three reported suicide attempts in 2018 and was considered a high risk for suicide.  She also continued with psychotic and depressive symptoms during part of the denial period.  

The documentation supports the need for approval in part.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Thyroglossal duct cyst.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned, in part. 

The patient is a male. The patient underwent excision of a thyroglossal duct cyst and was admitted post-operatively.

Yes, in part. The Inpatient admission was medically necessary, in part. Specifically, the inpatient admission was medically necessary for the inpatient day 1 only.

There was a laceration to the thyroid cartilage of the larynx during the surgery, which was primarily repaired.  The patient was started on POs (by mouth) on the night of surgery and was tolerating them.  Vital signs were stable and the patient was afebrile.  However, there were problems with pain control, as the mother was declining to give the child the prescribed pain medication.  There was no crepitus or other sign or symptom that there was air extravasation leaking from the laryngeal injury.  With the laryngeal injury and the risk of airway compromise secondary to this, the medical necessity of the inpatient date of service would be confirmed.  With the rest of the inpatient stay, due to difficulty with the mother administering pain medication and no explanation as to why hospital staff was not administering pain medication, the medical necessity of the inpatient days cannot be confirmed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mobility issues. 
Treatment: Personal Care Aide (PCA) services for a total of 168 Hours per Week (split-shift). 
The insurer denied Personal Care Aide (PCA) services for a total of 168 Hours per Week (split-shift). 
The health plan's determination is overturned in part. 

This is a case review for a female with medical history notable for mobility issues, incontinence, bilateral leg amputation, and history of sacral decubitus ulcer. The patient's physician provided a letter of support for this appeal. The letter states that the patient has had sacral decubitus ulcers in the past. With her bilateral leg amputations it is difficult for her to sit herself up and rotate. She requires assistance with all activities of daily living. There were no specific recommendations provided. 

Personal care aide services for 24-hours per day (live-in) is medically necessary for the patient. 

The patient requires personal care assistance for all activities of daily living. She is also incontinent of urine and stool, and requires assistance with frequent changes of incontinence care products. Her husband has been providing informal assistance, but due to his own health problems, will not be able to do so in the future. Because the patient's personal care needs are expected to be continuous and unscheduled throughout the day and occasionally at the night time as well, 24 hour live in personal care assistance is medically necessary for the patient. 

There is insufficient evidence that the patient requires 24-hour split shift personal care. There are no night time logs which demonstrate that the patient requires care overnight. The physician letter does not state that the patient requires turning and repositioning and she does not have any evidence of active pressure ulcer. Therefore, personal care aide services for 24 hours per day (live-in) are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Synovial sarcoma.
Treatment: Inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is modified.

This is a male with a history of a connective and soft tissue malignant neoplasm. He had a gastric/mixed tumor. The patient had reconstruction of a left lower extremity defect with a pedicled left gastrocnemius muscle flap and a split thickness skin graft. During the admission, routine postoperative care was rendered. Pain was well controlled with intravenous patient-controlled analgesia. The patient was later transitioned to oral pain medication. Two Jackson Pratt (JP) drains, and a wound vac (vacuum-assisted closure device) were placed. Intravenous Cefazolin was started. The patient was non-weight bearing on the left lower extremity with a long leg splint. The left lower extremity was elevated and remained in extension at all times. There was increased swelling and pain in his left knee. Methadone was started. Incision vacuum assisted closure was removed by Plastic Surgery. Ambulation was encouraged with the help of crutches. There was left lower extremity swelling with ambulation. The brace was adjusted without issues. An ultrasound revealed a left leg, mid-calf, deep vein thrombosis. Lovenox was started. The patient worked with physical therapy. He was able to tolerate an advancing diet. The patient was discharged home with home nursing services.  

The health care plan acted reasonably in part and with sound medical judgment and in the best interest of the patient. The initial admission was necessary, but a continued stay was not medically necessary.

The medical records demonstrate the patient had a unique and complex clinical condition. He had been diagnosed with a synovial sarcoma and required complex reconstructive surgery. His post-surgical course demonstrated several factors to substantiate necessity of ongoing acute hospitalization. He was found to have ongoing pain not responsive to initial pain management consultations. He required multiple medications with ongoing pain levels of 10/10. He required wound care and had a drain. There was continuous output for several days after his operation. It would be important to monitor evidence of bleeding and/or wound problems. He received wound care on a continual basis. His operative site was at high risk for complication. A person with a draining wound should not be discharged to a lower level of care. He also required ongoing intravenous antibiotics. Discharge planning was not completed until he was advised to apply for subacute rehabilitation.

Based upon the complexity and extent of his condition with high risk for complication, admission during the first 9 days would be medically necessary (ongoing pain, presence of drain, ongoing intravenous antibiotics, wound care).

Based on the above, the medical necessity for the continued inpatient hospital admission is partially substantiated. The insurer's denial is modified. Approve for initial 9 hospitalization days and uphold denial of the last 7 days of hospitalization.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neck and back pain
Treatment: Chiropractic Services (CPT Code: 98943, 97140.59, 97530, 97012)
The insurer denied the Chiropractic Services (CPT Code: 98943, 97140.59, 97530, 97012).
The denial is partially overturned.

The patient is a female. According to the documentation, the patient presented for chiropractic evaluation and treatment. The attending practitioner noted that the patient had a history of back and neck complaints with no real etiology noted.

Upon evaluation the attending practitioner diagnosed the patient with the following: pain in the thoracic spine, muscle spasm, subluxation to the thoracic spine, pain in the right shoulder, insomnia, depression and anxiety. A course of treatment was implemented to the patient by the attending chiropractic practitioner, which consisted of modalities including traction, manual therapeutic techniques, rehabilitative techniques in addition to manual manipulative techniques to the spine as well as extremity.

The patient underwent a follow-up treatment with the attending chiropractic practitioner, and it was proposed that treatment would be warranted.

Yes, in part. The requested Chiropractic Services (98943, 97140.59, 97530, 97012)  were medically necessary, in part.
Specifically, the 97140.59 manual therapeutic techniques utilized by the attending chiropractic practitioner would not be considered reasonable or necessary concerning this case. Such procedures performed concurrently as the manual manipulation (i.e., 98941) as provided by the attending practitioner to the patient in the same or similar region being manipulated would not conform to proper treatment and therefore not supported through the records submitted.

However, all other codes performed to the patient by the attending practitioner from consisting of 98943, manipulation of extremity joint, 97530, kinetic activities as well as 97012, traction would be considered reasonable, necessary and supported through the records submitted concerning this case.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, in part.
As explained through the rationale to question number 2, all codes rejected by the health plan other than 97140.59 would be considered reasonable, necessary and supported concerning this particular case. To deny codes 98943, 97530 and 97012 would not be in the patient's best interest.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pannus. 
Treatment: Outpatient services (surgery to remove excess skin on abdomen) (15830, 15847) x1. 

The insurer denied: Outpatient services (surgery to remove excess skin on abdomen) (15830, 15847) x1.  The denial is partially overturned. 

The patient is an adult female. This female has lost weight following bariatric surgery. She has an abdominal pannus and complains of recurrent rashes in the folds under the pannus. Dermatology note recommended anti-fungal medication and cleansing soap. Photos show a female with rashes in the fold under her pannus. Panniculectomy and abdominoplasty are planned. 

The panniculectomy is medically necessary; however, the abdominoplasty is not medically necessary. 

A panniculectomy (15830) is medically necessary, but an abdominoplasty (15847) is cosmetic. According to the American Society of Plastic Surgeons (ASPS) Position Paper "Treatment of Skin Redundancy For Obese and Massive Weight Loss Patients" (1), "When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature... For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. In situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic. Only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically, these procedures are performed to improve appearance and are therefore cosmetic in nature." 

The records indicate that the patient has failed conservative treatment for her longstanding rashes including medical treatment by her primary care physician (PCP) for at least six months with nystatin. Photos show she has an overhanging pannus with rashes. A panniculectomy will be sufficient to treat her rashes. This procedure will eliminate the overhanging abdominal skin that predisposes the patient to recurrent skin infections. Removal of redundant upper abdominal skin, diastasis repair and umbilical transposition are component parts of an abdominoplasty that are not necessary to treat the rashes. 

According to the American Society of Plastic Surgeons, "In the case where a panniculectomy is combined with plication of the rectus abdominis muscle and/or translocation of the umbilicus, this may be completed as a single stage procedure but the plication of the rectus abdominis muscle and/or translocation of umbilicus should be considered purely cosmetic..." An abdominoplasty is a cosmetic body contouring procedure that will not confer any additional functional benefit for this patient. A panniculectomy with skin resection is sufficient to treat this patient's infections.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma, macular degeneration, vertigo and early dementia

Treatment: Increase in PCA (personal care assistance) hours to live-in per diem, 24 hours per day, 7 days per week

The insurer denied coverage for Increase in PCA hours to live-in per diem, 24 hours per day, 7 days per week

The denial is modified 

This is a patient with chronic medical problems including asthma, macular degeneration, vertigo and early dementia. He lives alone in a 2-bedroom private home. The patient is currently receiving personal care assistance 5 hours/day, 7 days/week (35 hours/week total) and is requesting live-in per diem, 24 hours per day, 7 days per week, which is under review.  

The patient was admitted to the hospital, after a fall, transferred to a skilled nursing facility then eventually discharged home. According to the Uniform Assessment System (UAS) report, his cognitive status is "minimally impaired."  He is "able to identify emergency plan by calling/activating PERS (personal emergency response system)." The patient requires extensive assistance for activities of daily living including dressing, bathing, personal hygiene and toilet transfers/use. He is continent of bowel and (frequently) incontinent of bladder.   During the evaluation, he "was observed ambulating/transferring with use of walker and some weight bearing assistance provided by caregiver." According to the UAS report his functional ability has declined/deteriorated over the past 90 days. The clinical records do not substantiate a level of physical/cognitive impairment or debility to warrant an increase in PCA hours to the requested live-in per diem, 24 hours per day, 7 days per week as medically necessary. However, his recent falls history and functional decline support an increase in PCA services to 12 hours/day, 7 days/week in order to allow him the ability to live safely in his home.  

From a physical medicine and rehabilitation perspective, level 2, live-in per diem, 24 hours per day, 7 days per week is not medically necessary. However, an increase in PCA services to 12 hours/day, 7 days/week is medically necessary.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. The insurer's denial of coverage for personal care aide level 2, live-in per diem, 24 hours per day, 7 days per week is modified. An increase in PCA services to 12 hours/day, 7 days/week is medically necessary. Medical Necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure, prostate cancer and pleural effusion.

Treatment is an increase in personal care services (PCS) to 12 hours 7 days a week (total 84 hours/week).

The insurer denied coverage for an increase in personal care services (PCS) to 12 hours 7 days a week (total 84 hours/week).
 
The denial is modified.

This is a patient with chronic medical problems including congestive heart failure, prostate cancer and pleural effusion. He lives with his spouse in a 2 bedroom apartment and is receiving hospice services. An increase in personal care services (PCS) from 10 hours 5 days a week and 3 hours 2 days a week (total of 56 hours) to 12 hours 7 days a week (total 84 hours/week) is requested and currently under review.  

The Uniform Assessment System (UAS) report was reviewed. The patient is alert, oriented, self-directing and able to make his needs known. He is able to call 911 or activate PERS (personal emergency response system) in an emergency situation. The patient requires maximal assistance for bathing, personal hygiene, dressing and toilet transfers/use. Extensive assistance is required for bed mobility and eating. He is frequently incontinent of bladder and continent of bowel. He is non-ambulatory and wheelchair dependent. The patient's significant functional impairments support the medical necessity of consistent personal care services. However, his condition and functional needs are not at a level or as unpredictable to require the requested PCS 12 hours 7 days/week (total 84 hours/week). However, the patient's health and safety can be appropriately provided and maintained by increasing PCS services to a more consistent 10 hours/day, 7 days/week (total 70 hours). 

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

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested Personal Care Services (PCS) 12 hours 7 days a week totaling 84 hours is not medically necessary.  However increasing PCS to a more consistent 10 hours/day 7 days/week (70 hours) is medically necessary.  

The insurer's denial of coverage for personal care services, 12 hours 7 days a week totaling 84 hours is modified. Medical Necessity is partially substantiated
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Developmental Delay. 
Treatment: Pediatric medical day care 5 days per week. 

The insurer denied coverage for pediatric medical day care 5 days per week. 

The denial is modified. 

This is a female patient with speech and developmental delay. The patient has been receiving physical, occupational, and speech therapy services. Prognosis is documented as fair. The patient is enrolled in a Pediatric daycare and is requiring assist for all mobility, and self-care. The patient is medically stable, per records. 

As per the appeal "the child requires at least 3 days per week of service to provide all needed therapies, mealtime, therapeutic recreation and nursing care. [Physical Therapy] PT, [Occupational Therapy] OT, [Speech Therapy] ST plus the rest cannot be managed in 2 days." 

"Delay in development occurs when the child fails to attain developmental milestones as compared to peers from the same population. It is caused by impairment in any of the following distinct domains, such as gross and fine motor, speech and language, cognitive and performance, social, psychological, sexual, and activities of daily living (ADL). It can be isolated (involving a single domain), multiple (involving two or more domains, or global (affecting most developmental areas). In order to avoid long term disability, early detection, and intervention is warranted. This activity reviews the role of the interprofessional team in the comprehensive evaluation of developmental delay using standardized developmental surveillance and screening instruments in addition to lab workup and imaging." (Khan, et al., 2021). 

The health care plan did not act reasonably in part with sound medical judgment and in the best interest of the patient. The approved two days per week by the insurer is not sufficient to provide services to this patient, three days would be more appropriate for PT/OT and ST services.                                                    

The insurer's denial of coverage for pediatric medical day care 5 days per week is modified to allow for 3 days of pediatric medical day care. Medical Necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abscess
Treatment: D2751 White Glass With Metal Crown, Tooth 26
D3310 Nerve Treatment on Front Tooth, Tooth 26
The insurer denied the D2751 White Glass With Metal Crown, Tooth 26
D3310 Nerve Treatment on Front Tooth, Tooth 26
The denial is overturned, in part.

The patient is a female. The patient has an abscess at root apex of tooth #(number) 26. The tooth needs a root canal procedure. Denial was because the tooth was stated to have less than 50% (percent) bone support. The request is for root canal procedure and crown for tooth #26.

Yes, in part. The requested health service is medically necessary, in part.

Specifically, the requested root canal procedure is medically necessary, however, the requested crown for tooth after root canal is not medically necessary.

Tooth #26 has a periapical abscess at the end of the root from a dead/infected nerve. The root canal procedure is the only way to treat this problem, and it is medically necessary. The tooth has 75% bone support left, not the < (less than) 50% bone support as previously stated. There is definitely more bone holding this tooth in place than has been reported, and there is no need to remove this tooth once the root canal procedure has been performed.

The crown, however is not needed. This tooth has no decay or fractures, and the small access hole that will be created to do the root canal procedure can easily be filled with a small filling. The requested crown is not medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, in part.