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

Diagnosis: Syncope
Treatment: Inpatient Admission
The health plan denied the requested inpatient admission as not medically necessary. The health plan's determination is overturned, in part.

At the time of his admission, the patient was diagnosed with schizophrenia and catatonia, was brought to the emergency department the evening before with multiple episodes of unresponsiveness lasting up to fifteen minutes. He was on Abilify and a selective serotonin reuptake inhibitor (SSRI) with a slow tapering of Abilify by psychiatry, as he showed slow improvement. Vital signs at triage were normal and his exam was normal; although he was non-verbal, he followed commands and had an otherwise normal neurologic exam. This was baseline according to family. Laboratory was notable for an elevated creatine kinase (CK). Differential diagnosis was seizures, given the elevated CK, versus exacerbation of his underlying psychiatric illness, although it was noted that catatonia is not typically episodic. He was admitted to pediatrics, where his vital signs and physical exam were normal and mental status remained baseline. Neurology consulted and recommended admission for "24-hour observation for additional events" and a magnetic resonance imaging (MRI)/electroencephalogram (EEG). Given the severity (length) and multiplicity of the events, cardiology was consulted, and noted the electrocardiogram (EKG) was normal. A bedside echocardiogram was normal, and cardiology signed off. Neurology continued the EEG to capture an epileptiform event, should it occur, corresponding to symptoms. Subsequently, Psychiatry saw him for the first time, and cleared him for discharge home.
At issue is the medical necessity for the inpatient stay.

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

The first day's admission was medically necessary, given the multiple events and unusual length (for the patient) of the events.

Cardiology signed off on the day of admission after reviewing the EKG and performing an echocardiogram. Neurology saw the patient on the day of admission and stated that the patient should have a period of observation for further events and possibly an MRI and EEG. The patient did not have further events, but the neurology team decided to go ahead and do an MRI and multi-day EEG as part of the overall workup, a workup which could have been completed electively as an outpatient rather than as an acute inpatient. The length of stay was directly related to the length of the elective EEG. The first day was medically necessary to ensure neuropsychiatric stability. The rest of the days were not.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal/Low Back Pain.
Treatment: Surgical Services/posterior lumbar interbody fusion (PLIF) at the levels of lumbar vertebrae 3-4 (L3-4) and lumbar vertebrae 4-5 (L4-5) with decompressive laminectomy and 1 inpatient bed stay. 
The insurer denied the surgical procedures, posterior lumbar interbody fusion (PLIF) at the levels of lumbar vertebrae 3-4 (L3-4) and lumbar vertebrae 4-5 (L4-5) with decompressive laminectomy and 1 inpatient bed stay. as not medically necessary. 
The determination is overturned, in part.

The patient is a female with a history of low back pain and bilateral leg pain. She underwent physical therapy, chiropractic therapy, injections and medications without relief. She is a current smoker. The neurologic exam shows left leg weakness. The lumbar magnetic resonance imaging (MRI) shows severe spinal stenosis in lumbar vertebrae 3-4 and moderate to severe foraminal narrowing in lumbar vertebrae 4-5. 
At issue is the medical necessity of the requested surgical procedures.

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

The lumbar decompression is medically necessary; however, the lumbar fusion is not medically necessary.  
The patient has spinal stenosis (lumbar) L3-5 but there is no spondylolisthesis or instability.  The literature does not support fusion in this circumstance.  Thomes et al cite, "the addition of fusion to decompression did not result in improved outcomes at 3, 12, or 24-month follow-up. The addition of fusion to decompression provides no advantage to decompression alone for the treatment of patients with neurogenic claudication secondary to lumbar stenosis without spondylolisthesis or deformity." 
The decompression is medically necessary and supported by the literature. Lurie et al cite "in the as-treated analysis combining the randomized and observational cohorts of patients with spinal stenosis (SpS) those treated surgically showed significantly greater improvement in pain, function, satisfaction, and self-rated progress over eight years compared to patients treated non-operatively." The North America Spinal Society (NASS) guidelines state "Decompressive surgery is suggested to improve outcomes in patients with moderate to severe symptoms of lumbar spinal stenosis. Surgical treatment may be considered to provide long-term (4+ years) improvement in patients with degenerative lumbar spinal stenosis and has been shown to improve outcomes in a large percentage of patients." 
The 1-day hospital stay for a lumbar decompression is medically necessary due to the length of the surgery, post-operative pain and the use of a post-operative drain.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke.

Treatment: Skilled Nursing Facility.

The insurer denied coverage for continuing skilled nursing facility admission.

The denial is modified.

 
This is an adult with chronic medical problems including diabetes, stroke and substance abuse. He was initially admitted to the Skilled Nursing Facility (SNF). During his stay he developed hypoglycemia and sepsis that required transfer to an acute care hospital.  He was readmitted to the SNF. Under review is the medical necessity for continued stay at the SNF.

The patient was initially appropriate for the SNF level of care during the first and part of the second SNF admission. (1, 2, 3) His clinical condition and functional deficits were amenable to medical intervention and comprehensive rehabilitation. However, the treatment notes after the second admission document only modest improvement. The patient improved to the supervision level for bed and wheelchair mobility. He required only set-up for transfers and able to ambulate household distances with a rolling walker (100 feet). Performing activities of daily tasks such as hygiene and dressing was at the contact guard assist level. By this time, the patient's diet was mechanical soft with thin liquids. Subsequent improvement could have been attained at a lower level of care such as long-term care, home care with visiting therapy services or as an outpatient. In addition, there were no specific acute medical or complicated nursing issues that required continued stay at the SNF, again could have been provided via long term care or home with visiting nursing services.  

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 continued stay in Skilled Nursing Facility should be modified. 

Medical necessity for continued stay at the SNF is partially substantiated. SNF from the readmission up to 12 days is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with past medical history significant for coronary artery disease (CAD) with stenting, Atrial fibrillation not on anticoagulation, epilepsy and non-compliance with Keppra, ethanol (EtOH) abuse, and prior subarachnoid hemorrhage, who presented to the emergency department (ED) after the patient had had a seizure at home.  The patient also reported dark stools for the previous three days.  The patient denied nausea, vomiting, abdominal pain, chest pain, fevers, or chills.
The health plan's determination is overturned in part.  The inpatient hospital admission was medically necessary for the part.  The inpatient hospital admission was medically necessary for the first days in question and was not medically necessary for the last day of the admission.  This patient presented with a 5-point drop in his HGB from 12.6 to 7.6 on admission with associated hemodynamic instability with tachycardia, in addition to positive orthostasis on presentation.  Though his vital signs improved after 1U of PRBCs as did his hemoglobin, EGD showed an actively oozing AVM in the duodenal bulb, which is a lesion at high risk for re-bleeding.  He was maintained on Protonix with close monitoring for re-bleeding.  Inpatient admission for this patient with tachycardia, orthostasis, and a 5-point drop in his hemoglobin from baseline with an actively bleeding duodenal AVM was medically necessary.
The inpatient stay was medically necessary for this patient until the last day in question, at which point the patient could have been discharged.  This patient, as noted above, presented with a 5-point drop in hemoglobin from baseline, orthostasis with the heart rate increasing to 140 withstanding, and a duodenal AVM that was high risk for re-bleeding.  Admission, treatment with Protonix drip (gtt), esophagogastroduodenoscopy (EGD) with intervention, and post-procedure monitoring to ensure the patient was not re-bleeding was medically necessary.  Once it was noted the patient's hemoglobin was stable post-procedure, and the patient was taking a regular diet, the patient likely could have been treated at a lower level of care.  Admission at the inpatient care was medically necessary in-part.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: chronic obstructive pulmonary disease (COPD).
Treatment: inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is overturned in part.

The patient is a female with severe chronic obstructive pulmonary disease (COPD), chronic hypoxemic respiratory failure on 3-4 L (liters) home O2, hypertension (HTN), coronary artery disease (CAD), gastroesophageal reflux disease (GERD), with recent admission to the hospital for a COPD flare. She returned less than a week after discharge with chest pain and worsening dyspnea. For respiratory distress, she was started on NIV (non-invasive ventilation) by the Emergency Medical Services (EMS).

An inpatient admission was medically necessary for 5 days.

The patient presented with respiratory distress and acute or chronic respiratory failure requiring NIV in the setting of severe underlying COPD. She also presented as a failure of outpatient treatment, having just been discharged with a COPD flare and returning while still on the treatments from the prior admission. All of this indicates a high baseline level of severity and a high level of acuity for the acute presentation. Given all of this, she was severely ill at presentation and was at high risk of worsening. For this reason, she required an inpatient admission for close monitoring (especially given NIV requirements failure risk and the need for invasive mechanical ventilation). However, she had been weaned off of rescue non-invasive ventilation and was only on nocturnal NIV and had also improved to baseline (had persistent, gradually improving shortness of breath (SOB) that was still worse than baseline and still quite severe. Therefore, an inpatient admission was indicated.
However, after 5 days, she was at baseline and felt to be medically ready for discharge. Her discharge was held up not for medical reasons but as they were waiting to see if she could go to rehab. The team felt she was ok for discharge. As such, an inpatient admission was needed on these days.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health/Other/Confusion and an inability to concentrate on simple tasks
Treatment: Inpatient Stay
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is overturned, in part.

At the time of her admission, the patient was a female with a past history of sexual abuse and post-traumatic stress disorder, brought to the emergency department (ED) by her mother for a psychiatric evaluation. The ED note documents the mother saying her daughter has been acting differently, confused, and slow," and that she has a therapist and has been prescribed Sertraline, but mom is not sure if she has been taking it. The patient denied drug use and stated she wanted to 'live her life." The vital signs and physical exam were normal; the mental status exam documented that she answered questions inappropriately after significant pause and appeared confused. A complete blood count (CBC), metabolic panel, liver panel, urinalysis (UA), pregnancy test, viral respiratory swabs, electrocardiogram (EKG), and toxicology screen were all negative or normal. The ED documents she was "medically cleared for psychiatric treatment." She was admitted to the pediatric floor for further workup of organic causes of her altered mental status. The assessment on the admission history and physical was that the presenting problem was "likely due to extensive psychiatric history as patient now is acting more like herself at bedside according to her mother. Physical exam (PE) and labs unremarkable. Will proceed with electroencephalogram (EEG) though as recommended by neurology and follow up on psychiatric recommendations to determine disposition." Psychiatry saw her on the day of admission and determined that "delirium or other abnormal brain activity (e.g., seizures)" that could cause fluctuating attention and mentation could not be ruled out. She was not on a psychiatric hold for danger to self or others. She had a normal magnetic resonance imaging (MRI) and a normal EEG and was discharged.
At issue is the medical necessity for the inpatient stay.

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

Yes. One hospital day to complete the workup for an organic cause of her altered mental status was medically necessary, given the presenting history of deterioration from her baseline psychiatric problems. That included the metabolic and toxicologic workup that had been completed in the emergency department, the MRI, the EEG, and neurologic and psychiatric consultations. Given that she was already improved and "acting more like herself" upon admission from the emergency department and did not have any worsening in the first hospital day, one hospital day should have been sufficient to complete the workup.
The extended medical stay beyond one hospital day was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hip Surgery.
Treatment: Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is overturned in part. A 1 day inpatient stay was medically necessary. 

This case describes a male patient with a complaint of left hip pain who underwent prior left hip pinning due to a fracture. He developed left hip arthritis and failed to respond to conservative treatment measures. He elected to undergo removal of hardware and total hip replacement surgery. The patient had a successful operation with no documented complications. The patient had an uneventful hospital course and progressed well with physical therapy after the operation. He was deemed stable for discharge to home with home health care. Under review is the inpatient hospital stay.

A 1 day inpatient stay was medically necessary. The patient underwent left hip removal of hardware and total hip arthroplasty. The records document that pain management consultation was necessary for appropriate administration of narcotics. This facilitated the patient's participation in physical therapy and allowed him to ambulate 110 feet and climb 4 steps on day 2. Thus, the inpatient hospital admission is justified based on the provided records and the recommendations of the current, peer-reviewed orthopedic literature.
On day 2, however, the progress notes document that the patient noted good pain control with the current pain mediation regimen. The orthopedic progress note documented that the patient walked 110 steps and climbed 4 stairs. The noted also documented normal vital signs and lab values on this day. Based upon the provided documentation, the patient could have been safely discharged home on this day.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Asymmetry
Treatment: Masculine top surgery revision codes (13101. 13102, 14000, 14001, 15771 and 15772) consult for in-network coverage for an out of plan referral.
The insurer denied: Masculine top surgery revision codes (13101. 13102, 14000, 14001, 15771 and 15772) consult for in-network coverage for an out of plan referral to be performed. 
The denial is: Overturned in part.

The patient is a female to male transgender patient who underwent gender confirming mastectomies and now complains of asymmetry with too much tissue removed on one side and not enough removed on the other side. Despite the surgery he continues to bind his chest. 
On physical examination there were healed peri areolar incisions with bilateral chest contour deficits more so on the right and areolar skin creases also greater on the right and bilateral lower pole skin redundancies. An undated photo shows a deflated left breast with redundant lower pole skin/skin fold and right partially deflated breast. This is clearly outside the wide range of "normal" appearance determined by referencing the gender with which the patient identifies. Another set of undated photos show a slight indent on the left at 4 o'clock, minor excess lower pole breast tissue on the right, a significant right central mound depression, a basically normal male chest appearance without excess skin with the arms raised overhead, acceptable male appearing left chest with the arms down and normal male torso contour. The subject under review is the medical necessity for masculine top surgery revision codes (13101. 13102, 14000, 14001, 15771 and 15772) consult for in-network coverage for an out of plan referral. 

Based on the photos in the reviewed materials surgery on the left chest is not medically necessary because the left chest is inside the normal range of appearance for a male chest however, the right chest is outside the normal range of appearance for a male chest. Therefore, surgery on the right is medically necessary to create a chest contour within the normal range of appearance for a masculine chest.
13101 and 13102 are not medically necessary because they are global to/covered by 14001. Normal appearance on the right will require redistribution of the remaining subcutaneous tissue from the lower pole to the central mound. This will require 14001 and 15771 and 15772. Therefore, 14001, 15771 and 15772 on the right are medically necessary but surgery on the left and 14000 are not medically necessary. It is further not medically necessary that the patient have this performed by an out of network physician.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocarditis
Treatment LifeVest
The insurer denied the LifeVest.
The determination is overturned in part.


This is a patient with immune thrombocytopenic purpura (ITP), status/post splenectomy (s/p) , recurrent endocarditis, s/p tricuspid valve debridement and repair, strep G aortic valve endocarditis, treated for 6 weeks with ceftriaxone. She is s/p aortic and tricuspid valve replacements. She had complete heart block, with a pacemaker, then a Cardiac Resynchronization Therapy (CRT) device placed. She was admitted for right ventricular (RV) failure and severe aortic insufficiency with aortic valve endocarditis. She had a redo aortic and tricuspid valve replacement. Postoperatively, she had complete heart block, and the placement of a pacemaker. There was an issue with a lead malfunction, but the lead was not replaced. She was discharged to rehabilitation. A transesophageal echocardiogram (ECHO) showed severe biventricular dysfunction, left ventricular (LV) ejection fraction (EF) 20%, mild mitral and tricuspid regurgitation. The aortic valve gradient was elevated, but the prosthetic valve appeared to open normally. There was a possible thrombus on the prosthetic tricuspid valve. She was discharged with a LifeVest. She was re-admitted with polymorphic ventricular tachycardia (VT), requiring shocks from the LifeVest. She underwent an upgrade of her pacemaker to a biventricular implantable cardioverter defibrillator (ICD). Medications were adjusted, and she was started on a milrinone infusion which was continued at discharge. She was referred for a transplant evaluation.
At issue is the medical necessity of the LifeVest
Question(s):
The wearable defibrillator was medically  necessary in part during the waiting period for an implantable defibrillator. She has a dilated cardiomyopathy due to valvular heart disease, with aortic and tricuspid valve replacements and EF 20%. She met criteria for an ICD, but at the time of discharge had a temporary condition preventing ICD implant - recent surgeries and treatment for endocarditis. There are no reasonable, medically appropriate alternatives. The LifeVest is appropriate, and in this case, successfully resuscitated the patient from ventricular tachycardia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing teeth
Treatment: Implants For Teeth 5,10,12,13,14,15,18,19, 20, 30 and 31
The insurer denied the Implants For Teeth 5,10,12,13,14,15,18,19, 20, 30 and 31
The denial is overturned, in part

The patient is a female. The request is for dental benefits for implant placement for teeth #5, 10, 12, 13, 14, 15, 18, 19, 20, 30, 31.

Per the Provider's dental clinical summary, the patient has a failed partial denture history. She has a severe gag reflex, and she is unable to wear conventional partial dentures.

The health plan denied the claim because it was not medically necessary, and per their guidelines, they only approve implants when there is only one missing tooth in the arch, must have adequate bone and space for placement.

Yes, in part. The requested health service is medically necessary, in part.
Specifically, as it pertains to teeth #(number)s  5, 10, 12, 13, 14, 15, the implant placements are medically necessary. However, as it pertains to teeth #s 18, 19, 20, 30, 31, implant placements are not medically necessary.

As evident on the x-rays, the patient is missing teeth #s 5, 12, 13, 14, 15, and #10 is fractured and needs to be replaced.

If the patient is unable to wear a denture due to extreme gag reflex and the teeth that are missing do not lend themselves to be replaced by fixed bridgework, then the only option for restoration of function is implant placement.

With respect to teeth #s 18, 19, 20, 20, 31, the patient currently has fixed bridgework replacing teeth in those areas. There is no information in the dental clinical summary as to why these need to be replaced. There is not any overt gross pathology evident from the x-rays that would dictate implant placement for these teeth.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, in part.
The patient is missing five teeth on the maxillary (upper arch), four of these teeth are in the upper left posterior area such that the patient has no premolars or molars present to be able to effectively chew on the left side of the mouth.

Since the patient is unable to wear a partial denture, and the missing teeth do not allow for the configuration of a fixed bridge, there is no other alternative but implant placement.

By not approving this treatment, the patient will continue to have reduced function and the inability to chew on the left side of the mouth, this will eventually lead to increased stress on the dentition on the right side of the mouth as well as drifting of the teeth both inter and intra arch.

As it pertains to teeth #s 18, 19, 20, 30, 31, there is no information submitted that supports the removal of the existing fixed bridge prosthesis to be replaced by implants.