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

Diagnosis: Bipolar disorder
 
Treatment: Inpatient mental health treatment, medication, monitoring

The insurer denied the continued inpatient mental health treatment. The denial was modified.

This male was admitted for inpatient mental health treatment due to suicidal thoughts, depression, and psychotic symptoms including paranoid and delusional thinking, disorganized thinking, internal preoccupation, poor impulse control, flight of ideas, irritable and depressed mood, anxiety, pressured and hyperverbal speech, poor activities of daily living (ADL's), and non-compliance. He reportedly had been using crack/cocaine, K2 (synthetic marijuana) and alcohol. He had past reported psychiatric hospitalizations and a past reported suicide attempt. He had a diagnosis of bipolar disorder. 

The APA Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports the least restrictive level of care for safe and effective treatment is appropriate; patients with manic episodes, psychotic symptoms, or psychomotor agitation, aggressive or self-injurious behavior, suicidal or homicidal intent or plan are candidates for inpatient treatment. In this case, this patient had both manic and psychotic symptoms in addition to suicidal thoughts with a past reported suicide attempt, and alcohol and multiple substances of use, so he was considered a candidate for psychiatric hospitalization. 

As of day #5, the patient denied depression, hallucinations, paranoia, suicidal or homicidal ideation, plan, or intent. There were no reports of delusional or disorganized thinking or feelings of hopelessness. There were no specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting, and there were no reports of manic episodes, acute medical instability, or specific evidence that he was an imminent danger to self or others. 

Based on the above, inpatient hospital admission is modified to approve the first 4 days,  as medical necessity is substantiated, but deny remaining dates, as medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

The patient with a past medical history significant for benign prostatic hyperplasia (BPH) who was referred to the emergency department by the primary care physician for evaluation of fever, increased urinary frequency, and suprapubic pain that the patient  had for 3 days.
At the time of the initial evaluation, the patient complained of sharp suprapubic pain, which rated 9/10 in severity without radiation. At that time the patient stated that the  urine was dark in color and foul-smelling. The health plans determination is overturned in part. The requested health service/treatment of inpatient stay was medically necessary for this patient at the time of admission, based on the severity of the clinical condition and nationally adopted standards of care. The patient had a complicated urinary tract infection and pyelonephritis, therefore, in accordance with accepted standards of care, the required admission for the administration of intravenous antibiotics. The review of medical records demonstrated that the urine culture was finalized, and came back positive for pan sensitive Escherichia Coli. At that time the patient was afebrile, hemodynamically stable, and reported improved urinary symptoms that had brought the patient  to the hospital. Therefore, the hospital stay beyond the 3rd overnight was not medically necessary at the inpatient level of care. At that time, the care could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Orthopedic /Musculoskeletal/Joint problem.
Treatment:  Physical therapy.

The insurer denied Physical Therapy Services.  The denial is overturned in part. 

Records provided indicate that the patient has a history of a total knee replacement.  Records show the patient began physical therapy from a provider, and the providers were seeking authorization to provide coverage for these billed therapy services to include evaluation, two units of therapeutic exercise each on three separate days, one unit each of manual therapy and neuromuscular reeducation on three separate days, and two units of therapeutic activities.

The requested health service/treatment of physical therapy services was partially medically necessity for this patient.  The physical therapy evaluation was medically necessary.  The billed therapy services to include two units of therapeutic exercise each on three separate days, one unit each of manual therapy and neuromuscular re-education on three separate days, and two units of therapeutic activities were not medically necessary.

Per Department Of Health And Human Services Centers for Medicare & Medicaid Services, current procedural terminology (CPT) code 97163 is for physical therapy evaluation: high complexity, requiring these three components:  1) a history of present problem with three or more personal factors and/or comorbidities that impact the plan of care; 2) an examination of body systems using standardized tests and measures addressing a total of four or more elements from any of the following: a) body structure and function, b) activity limitations, and/or participation restrictions; 3) a clinical presentation with unstable and unpredictable characteristics; 4) and clinical decision-making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.  Typically, 45 minutes are spent face-to-face with the patient and/or family.  The physical therapy initial evaluation completed  meets these criteria.

However, regarding the remaining physical therapy services in question, progress notes for these three dates of service to include two units of therapeutic exercise each, one unit each of manual therapy and neuro-muscular reeducation, and two units of therapeutic activities billed did not include details for the treatment rendered on these dates to include specific exercises, number of reps, specific amount of time on each activity, etc. just require documentation support services billed.  Therefore, the physical therapy evaluation was medically necessary, and the remaining services in question were not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Suicidal ideation with multiple

Treatment: continued inpatient mental health treatment

The insurer denied coverage for continued inpatient mental health treatment. The denial is modified. 

This patient is a male was admitted to this inpatient mental health in this hospital due to suicidal ideation with multiple plans including overdose and hanging, psychotic symptoms including auditory hallucinations, responding to internal stimuli, disorganized thinking, paranoid delusions, circumstantial thinking, depressed and irritable mood, poor insight and judgment, guardedness, uncooperativeness, non-compliance with medications, and he was using cannabis. He had multiple past psychiatric hospitalizations and was homeless. He had a diagnosis of Schizoaffective Disorder. He took Latuda and Depakote. He reportedly was discharged.

The insurer denied coverage for continued inpatient mental health treatment in this hospital. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior, or inability to adequately care for basic needs are candidates for hospitalization. Notes reported auditory hallucinations, responding to internal stimuli, poor ADL's, noncompliance, poverty of thought, irritable and depressed mood, and he was uncooperative. Other notes reported that he still had depression, irritable mood, and auditory hallucinations. This was a high risk patient with continued psychotic symptoms who had 2 suicidal plans on admission, multiple past psychiatric hospitalizations, and substance use, and he required continued psychiatric hospital treatment then. He needed a day of observation without psychotic and severe depressive symptoms or suicidal thoughts and then was considered appropriate for discharge after a specified time. Other notes reported that he denied suicidal or homicidal ideation, plan, or intent, auditory hallucinations and that he did not want rehab follow up and was going to be discharged to the to another facility. He was discharged.
Continued inpatient mental health treatment in this hospital from specified dates was medically necessary, but continued inpatient mental health treatment in this hospital from other dates specified was not medically necessary.  It appeared that the insurer acted reasonably and with sound medical judgment and in the best interests of the patient from the latter date range but not from the former date range.

Based on the above, the medical necessity for the 14 units of the inpatient mental health treatment code 0124 is substantiated in part.  The insurer's denial is modified as noted above.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Caries, consistent with a failing existing restoration

Treatment: D2740 porcelain crowns on teeth #3, 4, 8, and 10 

The insurer denied coverage for D2740 porcelain crowns on teeth #3, 4, 8, and 10

The denial is modified

Upon review of the documentation provided which includes copy of panoramic and bitewing and periapical radiographs, pretreatment intraoral clinical photos, dental treatment notes and insurer correspondence, it appears that this patient presented to the dentist for comprehensive care. The treating dentist recommended full coverage crowns for teeth #3, 4, 8, and 10. The insurer has denied these services stating there is no clinical/radiographic evidence, such as traumatic injury or decay, provided to support the necessity of these services and therefore the service does not meet medical necessity criteria. The patient is appealing.

The objective documentation provided for review is a copy of intraoral clinical photos, panoramic and bitewing radiographs. 

In regard to teeth #3 and #4, although there appear to be failing preexisting restorations it appears that there is no evidence of fracture or other pathology specifically affecting these teeth based on the images provided for review that would justify full coverage restorations. The clinical photos and radiographs do not substantiate the requested dental services of full coverage crowns for teeth #3 and #4 and therefore the crowns for these teeth are deemed not medically necessary. 

In regard to teeth #8 and #10, upon review of the photos and radiographs, it supports the recommended treatment. Tooth #8 which is endodontically treated exhibits a crown with open margins on both the mesial and distal aspects of the tooth as well as possible recurrent caries, consistent with a failing existing restoration. There is ample coronal structure remaining. This tooth will have adequate residual coronal structure for support of a replacement crown and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be replacement crown which would have an excellent long-term prognosis with the recommended treatment. 

Tooth #10 clearly exhibits extensive caries both on the clinical photos and the radiographs. There is ample coronal structure remaining. This tooth will have adequate residual coronal structure for support of a crown and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be a full coverage crown as requested, which would have an excellent long-term prognosis with the recommended treatment.

The health plan acted reasonably in part.

The insurer's denial of coverage for D2740 porcelain crowns on teeth #3, 4, 8, and 10  is modified. Medical Necessity is substantiated for teeth 8 and 10; however, it is not is substantiated for teeth 3 and 4.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fracture Root Canal.

Treatment crowns (D2740) on teeth #4, 5 and buildups (D2950) on teeth #4, 5, and 14

The insurer denied coverage for crowns (D2740) on teeth #4, 5 and buildups (D2950) on teeth #4, 5, and 14

The denial is modified.
D2740 and D2950 for teeth #4,5 is not considered medically necessary for this patient.
D2740 and D2950 for tooth #14(15) is considered medically necessary forth patient.

Upon review of the documentation provided which includes copy of select periapical and bitewing radiographs, narrative letters and insurer correspondence, it appears that this patient presented to the dentist for comprehensive care. The treating dentist recommended full coverage crown for #4,5,14(15) and buildups. (There is a discrepancy as to which tooth 14 or 15 is at issue. The insurer notes tooth 14 the appealer notes tooth 15. Both teeth are in the same state). The insurer has denied these services stating the there is no clinical/ radiographic evidence, such as traumatic injury or decay, provided to support the necessity of these services and therefore the services do not meet medical necessity criteria. The patient is appealing.

The objective documentation provided for review is copies of select periapical and bitewing radiographs. It appears that there is no evidence of fracture or other pathology specifically affecting #4 or #5 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 dental services for these teeth as enumerated above and therefore the crowns/buildups are deemed not medically necessary for teeth #4 and #5.

As regards #14 (15) this tooth is endodontically treated. The dental standard of care in this circumstance is a buildup and full coverage crown. Therefore, the buildup and crown for tooth #14 (15) is considered medically/dentally necessary.

Uphold denial of coverage for D2740 crown teeth #4 and #5 as not medically necessary as the documentation is insufficient to justify or substantiate the treatment. Overturn denial and approve buildup and crown for tooth #14(15) as this would be standard of care treatment in dental practice for endodontically treated teeth.

The healthcare plan did act reasonably and with sound medical judgement and in the best interest of the patient for teeth #4 and #5. 

The healthcare plan did not act reasonably and with sound medical judgement and in the best interest of the patient for tooth #14 (15).

D2740 and D2950 for teeth #4,5 is not considered medically necessary for this patient.
D2740 and D2950 for tooth #14(15) is considered medically necessary forth patient.

The insurer's denial of coverage for crowns (D2740) on teeth #4, 5 and buildups (D2950) on teeth #4, 5, and 14 is modified. Medical necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental issue. 
Treatment: Alternate Benefit (D5213) for Pontic (D6241) on Tooth Number #4. 

The insurer denied: Alternate Benefit (D5213) for Pontic (D6241) on Tooth Number #4. 
The denial is partially overturned. 

The patient is an adult female requesting a three-unit bridge from tooth #3 to tooth #5 to replace missing tooth #4. The prior denial for the pontic crown on tooth #4 was due to the missing tooth clause and need for alternate benefit. 

The pontic crown on tooth #4 is medically necessary. The Alternate Benefit (D5213) is not medically appropriate for this case. 
The pontic crown for tooth #4 should be approved. The patient is only missing two teeth in her upper jaw, teeth #'s 4 and 13. To fabricate a partial denture for just these two teeth (with one tooth being on the upper right and the other missing tooth on the upper left) is not proper. There will be a lot of metal across the patient's palate to stabilize the denture. It is much better for the patient to place a bridge on teeth #3 through #5, rather than have a lot of unnecessary metal across the roof of her mouth to hold up two small teeth. Also her ability to taste food, speak and keep her teeth clean will be somewhat compromised with a partial denture. If the patient was missing more teeth in her upper jaw, the partial would be justified, but not for just two teeth with one being on either side. The letter also states that if less than three teeth are missing in an arch, the bridgework would be justified. The three unit bridge on teeth #3 through #5 with the pontic being #4 is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neonatal Care

Treatment: Inpatient admission

The insurer denied coverage for the inpatient admission.

The denial is modified. 

This is a newborn male infant who was born via spontaneous vaginal delivery. The mother was group B strep (GBS) positive and was prophylactically treated with intrapartum penicillin. The pregnancy was complicated because the mother was positive for COVID-19.  Initially, the infant was in the newborn nursery. However, the infant vomited 3 times overnight, and was transferred to the neonatal intensive care unit and admitted for observation. Blood work and a COVID-19 test were ordered. The infant's basic metabolic panel was normal. The infant remained in the neonatal intensive care unit, and he did not require any intravenous fluids. The infant tested negative for COVID-19. Following transfer to the neonatal intensive care unit, there was 1 other episode of vomiting. 

Despite the maternal history of COVID-19 during pregnancy, the infant initially was assigned to the well nursery on Day 1. Episodes of emesis prompted the transfer to the neonatal intensive care unit on Day 2. Blood pressures were within normal limits.  A partial sepsis work-up was said to be done, but this was only a complete blood count (CBC) and C-reactive protein (CRP). No blood culture was obtained.  No antibiotics were initiated. The history and physical stated the admission was for observation. On Day 3, the infant was discharged. 

The health plan acted reasonably in part.

The insurer's denial is partially overturned as follows: 
a)	Day 1: Only meets criteria for routine newborn care 
b)	Day 2: Meets criteria for Neonatal Care, Continuing Care, Level of 2 for observation for sepsis
c)	Day 3: Only meets criteria for routine newborn care, day of discharge.    

Based on the above, the medical necessity for the inpatient admission is partially substantiated. The insurer's denial is modified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fractured and decayed teeth. 
Treatment: Dental Procedures. 

The health plan denied the Dental Procedures. 
The health plan's determination of medical necessity is overturned, in part. 

The patient is a female who presents with fractured and decayed teeth. Crowns are being requested on teeth #7, #8, #9, #10, #12, and #13, and root canal treatment on teeth #12 and #13. 

At issue is the medical necessity of the requested treatment. 

The health plan's determination of medical necessity is overturned, in part. 

According to the submitted radiographs, there is no visible radiographic evidence of large decay or large missing tooth structure on teeth #7 and #8. Teeth #9 and #10 have small horizontal fractures on the incisal edge; however, the fractures are not missing enough tooth structure to warrant the need for crowns. Teeth #12 and #13 appear to have large decay on the distal surface of the teeth that are in close proximity to the pulpal horns. Therefore, root canal treatment for these teeth is warranted in this case. A tooth that is root canal treated has a high chance of fracturing due to loss of tooth structure from the root canal procedure. When a tooth with a root canal fractures, the tooth cannot be saved, and extraction is then needed. Therefore, crowns on teeth #12 and #13 are medically necessary to prevent fracturing of the teeth. 

As such, the request for crowns on teeth #7, #8, #9, and #10 is not medically necessary. However, the request for crowns and root canal nerve treatment on teeth #12 and #13 are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic hypoxic respiratory failure secondary 
to pulmonary fibrosis, moderate to severe dementia, major depression, hypertension, hyperlipidemia, benign prostatic hypertrophy (BPH) with incontinence, osteoporosis, and diabetes mellitus with difficulty walking
Treatment: Consumer Directed Personal Aid Service (CDPAS), 7 days x 24 hours Per day, split shift, A Total of 168 hours per week
The insurer denied Consumer Directed Personal Aid Service (CDPAS), 7 days x 24 hours Per day, split shift, A Total of 168 hours per week.
The denial is partially approved.

The requested health service is medically necessary, in part.
Specifically, increase to live-in services as opposed to split-shift is medically necessary.

The patient needs assistance with all activities of daily living due to overall all decline. He lives with his son who works long hours and is unable to assist. However, there is no indication that the patient's needs would prevent the aide from getting five hours of consecutive sleep. Therefore, an increase to live-in is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Chronic Obstructive Lung Disease/COPD
Nursing Services (including Private Duty Nursing)

The patient is a female with multiple medical problems including kyphosis, chronic obstructive pulmonary disease (COPD), diabetes and generalized debility. This review is for the medical necessity of increased personal care assistant hours to 42 hours a week. The patient requests an increase of personal care service hours from 7 hours per day 5 days a week to 7 hours a day 6 days a week for a total of 42 hours per week. The plan approved 35 hours a week.

The health plan's determination is overturned in part. Personal Care Assistance 6 days a week 6 hours per day for a total of 36 hours per week is medically necessary. The patient requires medical services daily. In the past, her husband was able to function to help her with some of the services on weekends however according to documentation provided he can no longer do so. The patient does have help for 1 day a week. Therefore, her needs would still be necessary every day of the week except Sunday because she has alternative help from another family member. However, service hours noted according to Uniform Assessment System (UAS) are in excess of the patient's needs. Therefore, 6 days a week 6 hours per day for a total of 36 hours per week is indicated. According to the UAS, this level of support is sufficient to meet the patient's needs. The hours were denied as the patient had a change in social circumstances since last assessment. However, the change has not impacted the patient's personal care assistance needs. After review of the assessment and plan of CARE, the recommendation is to continue current level of care. It is noted that the patient does require assistance with toileting, bathing, dressing, housekeeping as well as ambulation and transferring. It was noted that the patient was wheelchair bound and is only able to walk short distances. The Uniform Assessment System (UAS) noted that the patient required assistance with IADLs (Instrumental Activities of Daily Living) including meal preparation and housework and other level 1 services. The patient also required personal care aide services level 2 including showering, dressing, toilet transfer and incontinence care. It is noted that the patient ambulates with a walker. She does use oxygen. There is no noted hospitalizations. The patient is able to walk 150-299 feet at one time without sitting down to rest. The patient is not able to cook due to pain in joint and using oxygen. The personal care worker prepares all meals and spouse can reheat for member. In conclusion, a total of 36 hours per week are indicated.