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

Diagnosis: Osteomyelitis.
Treatment: Continued sub-acute rehabilitation.
The insurer denied: Continued sub-acute rehabilitation.
The denial is: Overturned in part.

The patient is a male with past medical history significant for hypertension, uncontrolled hyperglycemia, Parkinson disease, diabetes mellitus, osteomyelitis, peripheral vascular disease and schizophrenia who was admitted secondary to sepsis and right foot abscess status post surgical treatment of his right hallux by amputation. The patient was treated with intravenous antibiotics, along with skilled physical and occupational therapies.
The subject under review is the medical necessity for continued sub-acute rehab services. This was denied by the health plan based on lack of medical necessity.

The health plan's determination is overturned in part. 

The requested continued sub-acute rehabilitation is medically necessary in part. 
This patient with multiple medical problems was admitted for diabetic ulcer, osteomyelitis, status post amputation for treatment of the ulcer initially with IV antibiotics, wound care physical and occupational therapy.
Services were denied by the patient's insurance stating the following, criteria are not met because a note show that you have gotten better with therapy. Clinical notes state that your condition has improved, however your doctor thought that your wound was re-infected and started antibiotics for you again. The medical notes show that you will complete the antibiotics. You need little help getting dressed. You can bathe with a small amount of help. You can feed self with a little help. You can get out of a bed or chair with a small amount of help. You need a small amount of help with walking 90 feet and you can climb 8 steps with little bit of help. The notes show that you can go home once your antibiotics are completed. You do not need to stay in skilled nursing facility for therapy. Based upon the notes, you can get skilled services and therapy safely in a lower level of care if needed.
The plan approved additional dates of service.
IV antibiotics for infected diabetic foot wound were restarted with vancomycin and Cefepime with the treatment duration of 1 week.
As per the documentation, the patient's physical status has improved especially in regard to physical and occupational therapy. The patient can function in an alternate location with mild assistance. Currently the patient lives with family members and has a home health aide 4 hours a day 5 days a week. He has several steps (less than [<]10) into his residence, which he should be able to navigate according to physical therapy (PT). Continued inpatient skilled care is medically necessary until the completion of antibiotics. Therefore, inpatient skilled care would not be medically necessary after this. The patient requires no other ongoing skilled services that cannot be provided in a lower level of care setting.
Appeal type: Medical necessity
Decision: Overturned

Mental Health
Mental health inpatient 

Diagnosis: schizoaffective disorder
Treatment: inpatient mental health
The insurer denied Continued Stay for Inpatient Mental Health Level of Care 
The health plan's determination is overturned in part. 

This case involves an adult male with a longstanding diagnosis of schizoaffective disorder, bipolar type versus schizophrenia and bipolar disorder. The patient presented with symptoms of psychosis and agitation after stopping his medication. He was kicked out of the shelter where he was staying due to aggressive behavior towards others. He was not sleeping and was pacing which prompted his presentation to the emergency department. He was evaluated, medically cleared, and admitted to acute inpatient level care. He had been discharged from another inpatient psychiatric facility recently after a two-week stay.

Continued Stay for Inpatient Mental Health Level of Care for an additional 54 days was medically necessary. However, after this time, the patient no longer required the inpatient mental health level of care. 

In this case scenario, the continued inpatient level services were necessary in view of the continued acuity and risk for aggressive behavior and need for continued inpatient level structure and monitoring. The patient had not reached a level of stability that he could have been safely or effectively managed with lower-level services. The patient continued to need the intensity of services, structure, and monitoring of an inpatient setting.
However, after the additional time, it was not medically necessary for this patient to have 24-hour monitoring in an acute care setting in view of his relative lack of impulsive behaviors, diminished symptoms of psychosis, and improvements in mood and sleep and daily functioning. There were no general medical issues or co-occurring substance use disorders complicating this case that would have required continued inpatient level services.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple sclerosis (MS).
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission. 
The denial is modified.

This case involves a male with a history of primary progressive multiple sclerosis who presented to the hospital for evaluation due to a multiple sclerosis exacerbation causing left-sided weakness. The records indicated that he contracted COVID-19 virus 3 weeks before he was seen in the emergency department. He endorsed progressive weakness and was advised for an extension of inpatient stay. The patient received a notice of adverse determination stating that the inpatient stay was not medically necessary, and that the patient could have had his care rendered at a lower level.  An appeal was submitted stating that the patient initially presented to the emergency department with left-sided weakness and the inability to ambulate. He had a positive stool sample for sugar toxin producing E. (Escherichia) coli and was placed on contact precautions. Additionally, he was still testing positive for COVID-19.  The patient had abnormal vital signs with an elevated temperature and was positive for yeast on his sputum culture. Further findings included elevated liver function testing, with physical therapy assessments noting that the patient continued to require moderate assistance during standing. This review pertains to the denial of coverage for the inpatient stay extension.  

The Milliman Care Guidelines note that clinical indications for admission to inpatient care can include those individuals with multiple sclerosis or other demyelinating diseases who have an exacerbation requiring inpatient treatment.  Symptoms may include acute deterioration requiring inpatient treatment, severe pain requiring acute inpatient management, respiratory insufficiency requiring intubation or inpatient monitoring, inability to manage secretions, or weakness that is progressive or severe and inpatient care is needed due to functional disability and concerns for safety. The patient had initially been documented with a fever of 102.7 and extended care was indicated. However, records noted that the patient was hemodynamically stable and other than having 2/5 left lower extremity strength and 4/5 right lower extremity strength, he had discontinued Solu-Medrol, was on fall precautions, and was off contact precautions with no further episodes of diarrhea in over 48 hours. Given this information, it was determined that the patient could have been safely transferred to a lower level of care to include a skilled nursing facility where he could continue receiving treatment, observation, and assistance given his recent MS flare. He did not require any further extension of inpatient stay.


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

The insurer's denial of coverage for the inpatient stay extension is modified. Medical Necessity is substantiated for the first day of admission, but the denial is upheld for the extended stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic respiratory failure on continuous supplemental oxygen, atrial fibrillation and stroke
Treatment: Level 2 personal care services, per 15 minutes increase to 24 hours per day (live-in)
The insurer denied coverage for Level 2 personal care services, per 15 minutes increase to 24 hours per day (live-in).
The denial is modified.

This is an elderly female with medical problems including chronic respiratory failure on continuous supplemental oxygen, atrial fibrillation and stroke. She was recently discharged home from a rehabilitation facility. She lives with her husband in a private residence. The insurer approved personal care services (PCS) 28 hours/week and the request is for PCS 7 days/week, 24 hours/day, live in; (91 hours/week).

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as modified independent. She was noted as "alert and oriented x 3 (person, place, thing)." She was also "able to self-direct care." She is reportedly totally dependent for much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. Extensive assistance is reportedly needed for bathing, personal hygiene, dressing, locomotion, ambulation (walker and contact guard assistance) and toilet transfer/use. Limited assistance is reportedly needed for bed mobility and eating. She is frequently incontinent of bladder and continent of bowel. 

The patient's activities of daily living (ADL) status has declined over the prior 90 days and she reportedly fell at home (subsequently hospitalized for stroke, transferred to a skilled nursing facility and eventually discharged home). The patient's medical condition, cognitive deficits and physical limitations are not at the level or unpredictable as to require the requested PCS 24 hours/day live-in. Given the patient's reported general weakness and debility, she may benefit from additional safety monitoring. However, safety monitoring under personal care services (PCS) does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. However, the patient's functional ability has significantly declined when compared to the prior UAS. Based on the records reviewed and recent clinical events over the past 6 months; attention to the patient's functional needs are more appropriately provided and maintained by increasing PCS 12 hours/day, 7 days/week, shared household responsibility of other adult living in the home and informal care from family. 

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 Level 2 personal care services, per 15 minutes increase to 24 hours per day (live-in) services is not substantiated. However, increasing level 2 PCS to 12 hours/day, 7 days/week (total 84 hours/week) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure and Parkinson's disease
Treatment is 24 hours per day - split shift - personal care aide (PCA) services
The insurer denied coverage for 24 hours per day - split shift - personal care aide (PCA) services
The denial is overturned in part

This is a patient with chronic medical problems including congestive heart failure and Parkinson's disease.  She was hospitalized due to cardiac arrest and for sepsis. She lives alone in a private residence. The patient is approved by the insurer for 70 hours/week of PCA services and is requesting an increase to 24 hours/day - split shift.

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as "moderately impaired." She requires maximal assistance for bathing, lower body dressing and toilet transfer/use.  She is frequently incontinent of bowel and bladder. Extensive assistance is required for personal hygiene, upper body dressing and ambulation (uses a walker for short distances). Bed mobility requires limited assistance. Her functional ability for performing activities of daily living is much the same as was documented in the UAS report. However, since the more recent UAS assessment, the patient has been hospitalized and treated for cardiac and infectious disease conditions, which could contribute to a further functional decline. The combination of the patient's cognitive deficits and functional impairments support the medical necessity of increasing PCA to 84 hours/week. Her condition and functional needs are not at a level or unpredictable as to require the requested PCA 24 hours/day, 7 days a week - split shift. This physician would agree the patient may require 24-hour monitoring. However, safety monitoring under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by increasing PCA services to 84 hours/week.  

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, the requested 24 hours/day - split shift - PCA services, is not medically necessary. However, increasing PCA 84 hours/week is medically necessary.  

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 24 hours per day - split shift - personal care aide (PCA) services is not substantiated. However, increasing PCA hours to 84 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain, diarrhea and also fever.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned, in part. 

The patient is a male who had a prior history of hypertension and diverticulitis. The patient presented to the emergency room of the facility filing the appeal with the complaints of lower abdominal pain for one day preceding the admission. The patient had a previous admission two months earlier for diverticulitis which was treated conservatively. 

On this admission, the patient had moderate to severe abdominal pain, diarrhea and also fever. A computed tomography (CT) scan showed acute sigmoid diverticulitis as well as microperforations with free air under the diaphragm and multiple foci of intraperitoneal pericolonic free air. The patient was rendered nothing by mouth (NPO) and was started on intravenous (IV) antibiotics. The patient was seen by Surgery and Infectious Disease consultants. The patient's pain worsened with guarding and rebound tenderness and a repeat computed tomography (CT) scan was performed which showed air reabsorption. The patient continued to received intravenous antibiotics and a diet was advanced. The patient was discharged home on oral antibiotics.

Yes, in part; the proposed inpatient admission was medically necessary for the first five days of admission.  However, the proposed inpatient admission was not medically necessary for the remaining two days of admission.
The patient evidenced acute diverticulitis with microperforations, abdominal pain and free air under the diaphragm. The patient required an extended 'nothing by mouth' (NPO) period and close monitoring. The patient's length of care exceeded an observation level and the severity of his condition mandated a full, acute admission. 

However, by day six, the patient was tolerating oral intake with significant resolution of his pain.  As such, day six could have been the date of discharge.  The stay for days six and seven was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status post fall 
Treatment: Inpatient stay 

The inpatient stay was medically necessary, in part.

Summary:
The patient is a female. She was brought in by ambulance with complaints of back pain after slip and fall. She denied LOC (loss of consciousness).  She also c/o (complained of) left shoulder pain. 

CT scan shows L1 compression fracture.  The patient was reported to be in considerable pain and unable to ambulate without assistance. The patient reportedly lives alone. The patient was evaluated by orthopedics and found to be walking independently.  Orthopedics recommended pain management and stable for discharge. 

The patient was admitted for pain control.  PT (physical therapy) evaluated the patient.  The patient was treated with oxycodone and IV morphine.  The patient was discharged home. 

One night stay would have been appropriate. Hospital stay for one night was medically necessary to allow pain control and PT. This patient lives alone, so one night to allow her to get comfortable on pain medications, along with bracing, would have been sufficient. There was no medical indication for a prolonged stay of more than one night.  Orthopedics cleared the patient for discharge, and PT should have evaluated the patient within 24 hours and instructed on mobilization.
Appeal type: Medical necessity
Decision: Overturned

Schizophrenia
Mental Health: Inpatient

The patient is a woman with diagnoses of schizoaffective disorder (SCZAD) and Cannabis use disorder (CnUD). The patient presented to the emergency department (ED) with complaints of acute agitation, depressed mood, persecutory and paranoid delusions, beliefs in a conspiracy against her, fear of death threats. On evaluation in the ED, she also was noted to be hyperactive with pressured speech. She feared she would "lash out" at people. This fear indicated danger to others. She had clearly decompensated and required acute admission. 

The health plan's determination is overturned in part. Admission and dates of service (DOS) at the IMHT level of care were medically necessary for 10 days. After the 10 days, the patient could have been discharged. 

This patient's illness was severe and chronic. She faced severe psychosocial distress with homelessness and unemployment. She was non-compliant with her outpatient treatment. She was at risk for readmission if discharged before fully stabilized. This patient had to be treated for both her psychotic and mood symptoms. The treatment team for this patent recommended use of long acting intramuscular (IM) neuroleptics to prevent relapse. She had multiple past admissions. Future readmissions would most likely be less frequently required with long acting IM neuroleptics. Case notes document that she was still irritable and talkative, preoccupied, experiencing paranoid delusions, and refusing groups. She was less irritable and began to attend groups but not stabilized. She continued to refuse her long acting injectable of antipsychotic. She had a positive attitude for the first time, saying "It's going to be all right. I have a positive attitude." She had no suicidal or homicidal ideation. She was not delusional. Therefore, she could safely with good medical judgment be discharged after 10 days.
Appeal type: Experimental/Investigational
Decision: Overturned

Gender Dysphoria
Surgical Services

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 is a female to male transgender patient. The surgeon is proposing a shaft only radial forearm phalloplasty with Integra coverage of the donor site presumably followed by later skin grafting over the Integra. The dimensions of the expected area of coverage are not documented.

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.
Autologous skin grafting to the donor site in patients who undergo radial forearm free flap reconstruction (RFFF) is associated with cosmetic and functional morbidity. Integra artificial dermis (Integra Lifesciences, Plainsboro, NJ) is a bovine collagen based dermal substitute that can be used as an alternative to primary autologous skin transplantation of the donor site. Staged donor site reconstruction using Integra followed by ultrathin skin grafting results in highly aesthetic and improved functional outcomes for these defects and this has been documented as such in the medical literature for over 10 years beginning with radial forearm free flap reconstruction following head and neck cancer surgery. The Application of Skin Substitute is therefore likely to be more beneficial than any standard treatment or treatments involving singe stage skin grating for the insured. Given the typical dimensions of 15x17 centimeter (cm) or greater for such flaps, it is indicated.
The operating microscope is not used in the placement of the Integra and is not indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anemia, diabetes, dementia, bipolar disorder, schizophrenia, heart disease, benign prostatic hypertrophy (BPH), and legal blindness

Treatment: consumer direct personal assistance services (CDPAS) 24 hours a day, 7 days a week (split-shift) totaling 168 hours

The insurer denied coverage for consumer direct personal assistance services (CDPAS) 24 hours a day, 7 days a week (split-shift) totaling 168 hours

The denial is modified

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as "moderately impaired." The patient is totally dependent to maximal assistance for Instrumental Activities of Daily Living (IADL) including meal preparation, ordinary housework, and shopping. The patient requires extensive assistance for bathing, personal hygiene, dressing, locomotion, ambulation, and toilet transfer/use. The patient is infrequently incontinent of bladder and continent of bowel. Limited assistance is needed for bed mobility and eating. There were no falls or hospitalizations over the prior 90 days. The combination of the patient's cognitive deficits and functional decline support the medical necessity of increasing Consumer Directed Personal Assistance Services Program (CDPAS) to 84 hours per week. The patient may require additional monitoring, particularly due to memory and balance deficits. However, safety monitoring under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, the patient's health and safety can be more appropriately provided and maintained by increasing CDPAS to 84 hours/week. 

From a physical medicine and rehabilitation perspective, the requested CDPAS 24 hours a day, 7 days a week (split-shift) totaling 168 hours are not medically necessary. However, CDPAS 84 hours/week are medically necessary. 

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 direct personal assistance services (CDPAS) 24 hours a day, 7 days a week (split-shift) totaling 168 hours is not substantiated. However, CDPAS 84 hours/week is substantiated.