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

Diagnosis:  Glaucoma, Arthritis and Dementia.
Treatment:  Consumer Direct Personal Assistance program (CDPAP): live in per diem: 7 days per week.
The insurer denied coverage for CDPAP: live in per diem: 7 days per week. 
The denial is modified.

This is a very elderly woman with chronic medical problems including glaucoma, arthritis and dementia.  She lives with her daughter and son-in-law.  The insurer approved CDPAP: 8 hours per day - 7 days per week - for a total of 56 hours per week.  The request is an increased CDPAP to 24 hours/day (live in).

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 use.  Extensive assistance is needed for personal hygiene, upper body dressing, ambulation (with a walker), bed mobility and toilet transfer.  She is occasionally bladder incontinent and continent of bowel.  Limited assistance is needed for eating.  Her cognitive status has declined when compared to the UAS and her functional ability is much the same.  The patient's condition and functional needs are not at a level or unpredictable as to require the requested increased CDPAP to 24 hours/day (live in).  However, it is sufficient to support increasing CDPAP to 12 hours/day.  This physician would also agree the patient may require additional monitoring.  However, safety monitoring under personal care services (PCS) does not include monitoring an individual (e.g., with dementia) 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 the increasing CDPAP to 12 hours/day.  

From a physical medicine and rehabilitation perspective, the requested CDPAP: live in per Diem: 7 days/week is not medically necessary.   However, increasing CDPAP to 12 hours/day, 7 days/week, for total of 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 consumer direct personal assistance program (CDPAP): live in per diem: 7 days per week services is not substantiated. Increasing CDPAP to 12 hours/day, 7 days/week, for total of 84 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intraperitoneal bleeding following egg retrieval. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission.  The denial is modified. 

This is a female patient with no significant past medical history who presented to the Emergency Department (ED) for 3 near syncopal episodes. The patient was status post egg retrieval procedure. The patient reported that after the procedure, she went home and started to feel dizzy with lower abdominal pain. She also complained of shortness of breath and lightheadedness. Bedside ultrasound demonstrated free fluid in the abdomen. Gynecology (GYN) was consulted and recommended continuation of intravenous (IV) fluids and monitoring for intra-abdominal bleeding. The patient's hemoglobin was 9.8 grams per deciliter (g/dL). She was admitted as an inpatient to GYN Services for further evaluation of syncope, pain control and repeat lab work. During the hospital course, the patient's hemoglobin dropped to 6 g/dL, and she was treated with 1 unit of packed red blood cells. She was monitored and her pain was controlled. The patient was discharged home in a stable condition. 

During transvaginal oocyte aspiration, the aspiration needle may injure the adjacent pelvic organs and structures leading to serious complications. The most common complications are hemorrhage, trauma and injury of pelvic structures, and pelvic infection. The provider who performed the procedure stated that the egg retrieval was difficult, and he was concerned about injury to pelvic organs. 
 
This patient presented with intraperitoneal bleeding following egg retrieval. There was evidence of active bleeding, as the patient's hematocrit had dropped significantly and the patient was symptomatic. Admission to monitor for additional bleeding was necessary. 
 
Repeat complete blood count (CBC) showed a significant decrease in hematocrit necessitating a blood transfusion. However, following the transfusion the patient was feeling better with minimal pain. Her hematocrit was stable, and she could have been discharged that day. 

Milliman care guidelines list the clinical indication for inpatient care for patients with anemia. These include: active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, syncope. 

This patient had 3 syncopal episodes. Her egg retrieval was difficult. There was fluid in her abdomen and her hematocrit dropped significantly. 

Admission on day 1 of admission is considered medically necessary for this patient. Continued admission was not. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient in denying coverage for day 1 of admission but did act reasonably in denying the continued admission the days after. 

The insurer's denial of coverage for the inpatient hospital admission is modified. Medical necessity is partially substantiated. 

The insurer's denial of coverage for the inpatient hospital admission is modified. Medical necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure Disorder
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is partially overturned.

This is a male child with a complex medical history significant for hypoxic ischemic encephalopathy, spastic quadriplegic cerebral palsy, epilepsy, gastrostomy tube dependence, and scoliosis who presented to the emergency department (ED) with a seizure after a choking episode while at his pediatrician's office. The seizure lasted 40-50 seconds with stiffening extremities and eyes rolled back. He had been having choking episodes over the prior several weeks, had been seen in the ED a week prior for a similar episode, and had months-long history of abnormal breathing. The examination was significant for sleeping but arousable, no acute distress, moist mucous membranes, tachypnea, crackles at the left lung base, mild belly breathing, no nasal flaring, saturations fluctuating 91-93 percent (%), benign abdomen, hypertonia of extremities, contractures of extremities, and non-verbal. A chest x-ray revealed only kyphoscoliosis. Blood culture was pending. Rapid viral screen was negative. He was treated with a dose of albuterol and a dose of ceftriaxone and admitted for further management of suspected aspiration pneumonia.
Admission orders included nothing by mouth pending evaluation by speech and language pathology, medications per gastrostomy tube (GT), albuterol as needed, nebulized saline as needed, cough assist as needed, follow-up blood cultures, intravenous (IV) fluids at maintenance, home anticonvulsant medications, occupational therapy (OT) / physical therapy (PT) consultation, and home bowel regimen. Pulmonology was consulted with recommendations for additional airway clearance and an outpatient sleep study. Neurology was consulted with no changes in the medication regimen. 
The majority of the hospital stay was medically necessary and appropriate. Based on the documentation provided, the patient was tolerating his feedings, with stable body temperature for three days, tolerating enteral antibiotics, with no choking episodes. At this point, he was stable for discharge home. The discharge was held pending delivery of the chest vest because pulmonology had increased his airway clearance regimen to include the vest. He could have been safely discharged home  pending delivery of the vest the following day. It was possible to perform manual chest physiotherapy for airway clearance in the interim.
The final day of the hospital stay was not medically necessary. He could have been safely discharged the prior day.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, osteoarthritis, and dementia.

Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days a week - a total of 84 hours per week.

The insurer denied coverage for PCA Level 2: 12 hours per day - 7 days a week - a total of 84 hours per week.

The denial is modified .

This is an elderly male with multiple medical problems including diabetes, osteoarthritis, and dementia. He lives with his spouse in a private home. The insurer approved PCA 3.5 hours/day, 5 days/week for a total of 17.5 hours/week. The request is for PCA Level 2: 12 hours/day - 7 days/week - a total of 84 hours/week.

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Minimally impaired." He requires extensive assistance for lower body dressing, bed mobility, ambulation, and toilet transfers. Limited assistance is needed for personal hygiene, upper body dressing and toilet use. He is occasionally incontinent of bladder and continent of bowel. He is independent with eating. The patient's functional ability has declined compared to the previous UAS report. His condition and functional needs are not at a level, unpredictable or significantly declining as to require the requested personal care services (PCS) 84 hours/week. This physician would agree the patient may require additional monitoring. However, safety monitoring under PCS does not include monitoring an individual (e.g., with dementia) when no other Level I or Level II personal care services task is being provided. Given his functional decline and based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by the increasing PCA services 6 hours/day, 7 days/week, totaling 42 hours/week.  

From a physical medicine and rehabilitation perspective, PCA Level 2: 12 hours/day - 7 days/week - a total of 84 hours/week is not medically necessary. However, increasing PCA services 6 hours/day, 7 days/week, totaling 42 hours/week is medically necessary. 

Based on the above, the insurer's denial must be modified. The health care plan acted reasonably in part. 

The medical necessity for PCA Level 2: 12 hours per day - 7 days a week - a total of 84 hours per week services is modified to provide PCA services 6 hours/day, 7 days/week, totaling 42 hours/week.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle cell crisis and pneumonia
Treatment: Inpatient admission
Admission was medically necessary, in part. 

The patient presented with fever, pain and tachycardia.  Chest x-ray and CT were concerning for possible pneumonia.  Given his chest pain and shortness of breath, acute chest syndrome was also suspected.  Given those considerations and his continued difficulty with pain in the emergency department despite treatment with pain medication, the patient could not be managed at a lower level of care.  He had tachycardia but what was described as a stable blood pressure for him.  As of the third day, the patient could be managed at a lower level of care. He had no other significant issues, and notably no significant organ compromise or signs/symptoms suggestive of severe sepsis.  He did not have respiratory failure. He had no evidence of infection at that time and no recurrent fever or other acute medical issue active as of that time.  While it is noted that he had low-grade fevers with positive blood cultures following that, as of the third day he could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral Occipital Neuralgia and Intractable Chronic Migraine with Chronic Post-Traumatic Headache.
Treatment: Pain Management Injections (64405 (quantity 2) and 64400 (quantity 2)).
The insurer denied coverage for Pain Management Injections (64405 (quantity 2) and 64400 (quantity 2)).
The health plan's determination is overturned in part.

The patient is a male who is diagnosed with bilateral occipital neuralgia and chronic migraine. Treatment with bilateral occipital nerve blocks (current procedural terminology (CPT) 64405) and bilateral trigeminal nerve blocks (CPT 64400) is the subject of this review. 

CPT 64405 (quantity 2) or greater occipital nerve blocks are medically necessary for the treatment of the member's condition, occipital neuralgia. The nerve blocks are considered to be both diagnostic and therapeutic for this condition. Occipital nerve blocks with a local anesthetic and corticosteroids provides a safe, simple and effective treatment method for the patient with occipital neuralgia. The procedure is recognized by neurologists and pain management specialists as a standard treatment for this condition.

CPT 64400 (quantity 2) or original nerve blocks are not medically necessary. These injections are not a treatment for occipital neuralgia and are not a well-established therapy for treatment of other headache disorders such as chronic migraine or post-traumatic headache. These injections have not been shown to have a dural therapeutic effect. A subcommittee of the American Headache Society does not recognize these injections as medically indicated for treatment of migraine or occipital neuralgia.
The requested health service/treatment of pain injections is medically necessary in part for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pre-Term Labor

Treatment: Inpatient Admission

The insurer denied the inpatient admission. The denial was modified.

This is a female patient with a history of a spontaneous abortion. This is a pregnant female patient who presented to the Emergency Department with complaints of possible contractions. A cervical ultrasound was performed that revealed cervical changes; cervical length of 1.6-1.8. The tocolysis (TOCO) transducer revealed irregular contractions and irritability. The patient was admitted to the hospital with pre-term labor. The patient was treated with Celestone and magnesium sulfate. Intravenous (IV) fluids and IV antibiotics were administered. The patient was medically stabilized and discharged home. 

According to literature review, preterm labor is an indication for admission and for tocolysis treatment. Preterm labor is defined as uterine contractions with cervical changes. 

Based on the review of the medical record, this patient had documented cervical changes by ultrasound that met the criteria for preterm labor. So, inpatient admission was medically necessary for this patient to be treated with tocolysis and steroids. However, the next day, progress note noted that the patient had no cervical changes. At this point, because there was no evidence of any cervical changes, the patient no longer met the criteria for preterm labor. The patient's vital signs were stable and the fetal heart rate was reassuring, and there was no adverse event, such as ruptured membranes that warranted continued inpatient stay. Once the provider ascertained that there were no additional cervical changes, the patient could have been safely discharged the next day.  

The health care plan acted reasonably with sound medical judgment in denying coverage for the last couple of days, but did not act in the best interest of the patient in denying coverage for the day of the inpatient admission.

The carrier's denial of coverage for the inpatient hospital services at the acute inpatient level of care from is modified. The medical necessity is substantiated for the day of admission but not substantiated for the following days. Reverse the day of admission, and uphold the last couple of days.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: disc herniation

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is modified

This is an adult male who presented to the emergency department complaining of severe lumbosacral pain radiating to the right leg for 6 days. He took Tylenol extra strength and oxycodone IR (instant release) without relief of symptoms. He was scheduled for surgery the following week. However, surgery was rescheduled for the following day after his physician noted a large L (lumbar) 2-L3 central disc herniation with inferior migration. The patient was admitted for pain control and preoperative work-up prior to the L2-L3 laminectomy/discectomy. His pain control could have been rendered on an outpatient basis or under observational care. The surgery could have been completed on an outpatient basis as there were no complications following the procedure. An appeal letter was submitted stating that in addition to the L2 laminectomy, the patient required removal of an extra mass and an L3 revision with partial L4 laminectomy, excision of a migrated herniated disc behind the L3 vertebral body, and posterior lateral fusion with local autograft at L2-L3. Based on the risk for complication that could potentially affect neurological function, the patient required a higher level of monitoring and care. This review pertains to the denial of coverage for inpatient admission.

The Milliman Care Guidelines state that patients with low back pain typically will require hospitalization when they have severe pain that cannot be managed in the emergency department, have a suspected spinal infection, or have a suspected cause that requires inpatient treatment such as aortic dissection or spinal cord impingement. The guidelines state that in terms of lumbar fusion, the goal length of stay is 2 days postoperative.

Based upon the provided information, the prior determination is partially overturned to allow for partial coverage for the inpatient admission.

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 the inpatient admission is modified. Medical necessity is substantiated for 2 days. Medical necessity is not substantiated for 1 day. Medical Necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who underwent a right shoulder arthroscopy and rotator cuff repair, extensive debridement glenohumeral (GH) joint and subacromial decompression (SAD) with acromioplasty. The patient received 24 physical therapy visits for post-surgical shoulder related problems. Therapy requested 36 therapy visits. This was denied during previous review stating that the patient can manage her shoulder problem with a home exercise program and that the request did not meet criteria for medical necessity. The health plan's determination is overturned in part.
Additional physical therapy is medically necessary in part. The patient required physical therapy following rotator cuff repair. She developed right shoulder adhesive capsulitis. Standard of care for adhesive capsulitis is aggressive physical therapy. However, physical therapy 3x/week for 8 weeks (total of 24 visits) is medically necessary;  36 additional physical therapy visits without re-evaluation is excessive.
This is based on the patient's most recently follow-up with . While a physical exam did support that the patient's rotator cuff repair had healed with 5/5 strength of supraspinatus, infraspinatus and subscapularis she continued to have severe active and passive range of motion deficits with the diagnosis of right shoulder adhesive capsulitis. Active right forward flexion was 140 degrees (left 180), abduction 150 (left 180), external rotation 30 (left 80), internal rotation T12 (left L5). The need for physical therapy is also supported by the fact that despite the patient completing a home exercise program her active range of motion in her right shoulder had actually worsened.  Additionally manipulation under anesthesia was explained as an option but that "she would still require PT after that." Standard of care for shoulder adhesive capsulitis is continued aggressive physical therapy with or without manipulation under anesthesia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, diabetes and peripheral edema

Treatment: Personal care aide (PCA) level 2: 8 hours per day - 7 days per week - a total of 56 hours per week

The insurer denied coverage for personal care aide (PCA) level 2: 8 hours per day - 7 days per week - a total of 56 hours per week

The denial is modified.

 
This is an elderly female with chronic medical problems including hypertension, diabetes and peripheral edema.  She lives alone in a private residence.  The plan approved personal care aide (PCA) 28 hours/week.  The patient requested level 2: 8 hours per day, 7 days a week totaling 56 hours/week, denied by the insurer; leading to an external review.   

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as modified independent.  She is reportedly totally dependent to maximal assistance for completing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient also reportedly requires maximal assistance for bathing.  Limited assistance is reportedly needed for dressing, locomotion, toilet transfer/use and ambulation. The patient is independent with personal hygiene, bed mobility and eating.  The patient is reportedly frequently incontinent of bladder and continent of bowel.   Her activities of daily living (ADL) status has declined and there have been no reported falls over the prior 90 days. 

The patient's cognitive and functional ability have declined when compared to the prior UAS report. The Emergency Department note does not specifically address the patient's functional ability.  This physician would agree that the patient may benefit from monitoring for safety; particularly due to her reported cognitive deficits, weakness and falls risk.  PCA services for companion care or safety supervision (e.g., dementia, wandering, falls risk) without the direct provision of ADL task assistance is not a covered service.  However, given her modest cognitive and functional decline and based on the enclosed documents reviewed, this patient's health and safety are more appropriately provided and maintained by increasing PCA 6 hours/day, 7 days/week, totaling 42 hours/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 personal care aide (PCA) level 2: 8 hours per day - 7 days per week - a total of 56 hours per week services is not substantiated. However, PCA level 2: 6 hours/day, 7 days/week, totaling 42 hours is medically necessary.