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

Diagnosis: Infectious Disease. 
Treatment: Lab Work/Blood Tests. 
The insurer denied: 87491, 87591, 82652. 
The denial is overturned in part.

The patient is a male without significant past medical history who had vitamin D 1,25 dihydroxy blood test and chlamydia and gonorrhea nucleic acid testing. The diagnosis code for testing was Z29.8, Encounter for other specified prophylactic measure. The insurer denied coverage as not medically necessary.

Lab procedure 87491 and 87591 are medically necessary, and 82652 is not medically necessary.
The patient is a young male and sexually transmitted disease (STD) testing is a recommended screening for sexually active males and females depending on sexual orientation and sexual activity. Per UpToDate.com "The major rationale for chlamydia and gonorrhea screening among men is to reduce infection or reinfection of existing partners and transmission to new partners."
If a patient requests STD testing at an appointment that would be sufficient to order such testing without further investigation as to why the patient would want to be tested.   A provider may inquire if the patient feels they need to be tested for STDs as part of routine screening and if the patient agrees there may not necessarily be further discussion of symptoms, frequency of intercourse or sexual preference.  Certainly, a sexual history is appropriate to obtain from a patient but sometimes patients are not willing to disclose a detailed sexual history.  Given such, STD testing is medically necessary.  Young adults are sexually active and young adults should be screened for STDs even without specific symptoms or concerns. STD testing is medically necessary in this young male.    
There have been no specific medical societies who have recommended screening for Vitamin D deficiency and the U.S. Preventative Task for cites insufficient evidence to recommend routine screening for Vitamin D deficiency, therefore it was not medically necessary to screen for vitamin D deficiency in the absence of chronic kidney disease or intestinal absorption problems.  
The United States Preventive Services Task Force (USPSTF) found no studies that evaluated the direct benefit of screening for vitamin D deficiency in adults. The USPSTF found adequate evidence that treatment of asymptomatic vitamin D deficiency has no benefit on cancer, type 2 diabetes mellitus, risk for death in community-dwelling adults, and risk for fractures in persons not selected on the basis of being at high risk for fractures. The USPSTF found inadequate evidence on the benefit of treatment of asymptomatic vitamin D deficiency on other outcomes, including psychosocial and physical functioning. Although the evidence is adequate for a few limited outcomes, the overall evidence on the early treatment of asymptomatic, screen-detected vitamin D deficiency in adults to improve overall health outcomes is inadequate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anemia.
Treatment: Inpatient Admission.
The insurer denied the hospital stay.
The determination is partially overturned.

The patient is a female with severe anemia for which she presented to the hospital. Her admitting hemoglobin was 4.8 grams per deciliter (g/dL). The patient also was noted to exhibit profound leukopenia with a decreased white blood cell count and a decreased absolute neutrophil count. Transfusion support was provided to the patient and the patient was admitted for further evaluation. Her work-up revealed a vitamin B12 deficiency, evidence of alpha thalassemia trait, possible hemolysis, severe hypokalemia and considerations were made for possible bone marrow disease. With respect to treatment, in addition to red blood cell transfusion support, the patient received electrolyte repletion. She was eventually discharged 4 days later. The patient's healthcare plan has denied coverage for the patient's inpatient admission.

The patient's healthcare plan, in its determination of medical necessity and denial of coverage for the patient's hospitalization did not act in the best interest of the patient.
The patient exhibited profound anemia and thrombocytopenia. The acuity of such findings was not evident from the provided medical records however, such a severe degree of anemia is the major predisposition for cardiovascular and cerebrovascular events and would mandate for the patient to have transfusion support. An inpatient evaluation can exclude potential bleeding or overt hemolytic anemia. Either of these potential scenarios would mandate inpatient medical management. This opinion is further supported by consensus recommendations to evaluate severe anemia in an inpatient setting.
However, once the patient's hemoglobin and hematocrit stabilized and it was demonstrated the patient did not exhibit overt hemolytic anemia or gastrointestinal bleeding, a more expeditious discharge would have been appropriate.

I believe the medical service requested of an inpatient admission was medically necessary in this case. However, I do not believe a 4 day hospitalization was required. Upon stabilization of the patient's hemoglobin and hematocrit which was noted 48 hours post admission, the patient could have been discharged.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
 
Treatment: Inpatient substance rehabilitation treatment

The insurer denied the continued inpatient substance rehabilitation treatment. The denial was modified.

This patient is a male who was admitted to inpatient substance residential treatment as he was court mandated for 28 days of this treatment. He was using cocaine a few times per week with a 5 year history of use, and was abusing Xanax. He had a recent inpatient substance detoxification and an intensive outpatient program treatment. He continued to relapse. He continued to use substances despite past negative consequences. He had anxiety and was self- medicating with substances of choice. 

In this case the patient was considered in need of 24-hour substance rehabilitation treatment for at least 3 months as he continued to relapse despite past inpatient substance detoxification and Intensive Outpatient Program (IOP) treatment. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he met criteria for inpatient substance rehabilitation treatment as he continued to use multiple substances including large amounts of cocaine and Xanax despite past inpatient substance treatment and Intensive Outpatient Program (IOP) treatment. He was at risk for overdose and was considered a danger to self and others due to use as he had multiple arrests for drug related charges, lost his job, was homeless, was self-medicating anxiety, and could not maintain abstinence. The 28 days in this inpatient treatment was not considered enough treatment due to his significant amount of drug use and many negative consequences to use. 

The medical necessity for the continued residential treatment substance abuse rehabilitation level of care for the first 92 days is substantiated. The insurer's denial is modified. Approve the first 92 days; deny remaining dates.
Appeal type: Medical necessity
Decision: Overturned

Other
Inpatient Mental Health 
The patient is a woman with a diagnosis of schizoaffective disorder (SCZAD). Case notes document that the patient was experiencing auditory hallucinations (AH) for about two weeks prior to admission. She received an intramuscular (IM) dose of Haldol from her outpatient provider and was started on lithium. Despite the outpatient treatment, she continued to experience AH as well as depressed mood, insomnia, self-talk, low energy, and dysphoria. She went to the emergency room in distress and was admitted. She had required at least two prior psychiatric admissions due to her SCZAD, with at least one admission due to cannabis use disorder (CUD). The patient's illness under review apparently began 2 weeks prior when she again smoked Cannabis which precipitated her AH. Her treatment included increasing doses of Haldol as well as lithium. At one point in her treatment, she was given trazodone for sleep. In addition, she was treated with psychotherapy and milieu management.

The health plan's determination is overturned in part. The patient was continuing with AH. The AH distressed her and put her at risk. Schizoaffective disorders include symptoms from both the schizophrenia group of illnesses and the mood disorders/bipolar disorders spectrum. This patient had to be treated for both her psychotic and mood symptoms. Therefore, discharge based on her mental status could not have been predicted and would not be appropriate. Only in retrospect could it be determined to be safe, which is not the standard of care. She would be at risk for rehospitalization or self-harm if discharged. Her mental status did show improvement: She no longer had AH. She had no paranoia. Her mood was pleasant. She interacted freely. She stated she felt better. Therefore, she could be safely discharged for continued treatment at a lower level. This patient was chronically ill and has required two past IMHT at least one with attempted self-harm.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Thrombocytopenia

Treatment: inpatient hospital stay

The insurer denied coverage for inpatient hospital stay

The denial is modified.

According to the medical records, the patient has a history of brain meningioma, splenomegaly, portal hypertension, thrombocytopenia, chronic back pain and headache. She was admitted complaining of abdominal pain, body aches, headache, and generalized weakness x (times) 3 weeks.  She was admitted for further evaluation to Medicine Service, and she was treated symptomatically with acetaminophen. She was discharged.

Once oncology saw her and diagnosed her thrombocytopenia as chronic and not dangerous, there was no acute need to remain inpatient. Dates exclusive and after are not medically necessary.   There were, in the end, no new findings of diagnoses. Oncology had mentioned malignancy and planned a bone marrow for occult potential malignancy. Therefore, the continued stay was not necessary and gynecology consultation could have been done on an outpatient basis.

"Splenomegaly is one of the major clinical manifestations of primary myelofibrosis and is common also in other chronic Philadelphia-negative myeloproliferative neoplasms, causing symptoms and signs and affecting quality of life of patients diagnosed with these diseases. We aimed to study the impact that such alteration has on thrombotic risk and on the survival of patients with essential thrombocythemia and patients with Polycythemia Vera (PV)." (Accurso, V. et al.. 2019).                                                         
   
The health plan acted reasonably in part with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital stay is modified. Medical Necessity is substantiated for 1 day. However, denial is upheld for 2 days.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right hip closed displaced intertrochanteric fracture.
Treatment: Physical Therapy (97110).
The insurer denied coverage for Physical Therapy (97110).
The denial is modified.

This male sustained a right hip closed displaced intertrochanteric fracture after a skiing accident. He underwent right hip surgical repair. Post-operative physical therapy began thereafter.  

The physical therapy (PT) treatment notes after approximately 6 weeks of PT, provide limited quantitative or verifiable measures of improvement. However, the treatment notes document the services provided, response to treatment and significant improvement. Continuing a structured PT program for all of the time period under review was not medically necessary. For example, according to the PT note visit 24, the patient "went skiing today." He reported "not much pain when he came in for therapy." The patient no longer required structured PT after visit 24. Continued functional improvement would have been obtained via a home exercise program and gradually resuming his various recreational activities.  

Physical Therapy during the initial post-operative period, was medically necessary. Continued PT was not medically necessary.  

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

The insurer's denial of coverage for Physical Therapy (97110) is modified. Medical necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is Partially Overturned.

The patient is an adult female with medical history of obesity, hypertension, and hypothyroidism. The patient presented to the emergency room with complaints of right lower extremity swelling and redness. The patient gave history of a fall six days prior, for which she was seen in urgent care and underwent X-ray of the leg and was started on Keflex. The patient evaluated by her doctor on two days with worsening pain and no improvement of her cellulitis. The patient was sent to the emergency room for intravenous antibiotics. The patient's initial vitals were blood pressure 150/87, heart rate 72, respiratory rate 18, temperature 36.7 Celsius (98.1 Fahrenheit), and pulse oximetry 96%. Examination showed, erythema was noted on right lower extremity below knee that extended to the posterior area with 
warmth present. No fluctuance or abscess was noted. X-ray of her right lower extremity (tibia - fibula) demonstrated diffuse soft tissue swelling throughout the entire imaged extremity. In the emergency room, the patient received cefazolin intravenous. The patient was admitted to inpatient hospital stay for treatment and monitoring. Subsequently, on day #2, the patient was noted to be hypoxic and required monitoring and oxygen administration to stabilize her. On da #3, the patient was also noted to be hypoxic. The patient was continued on intravenous antibiotics and improved.

The Inpatient admission was medically necessary, in part.

Specifically, inpatient hospital stay was appropriate for the initial 4 days. Inpatient hospital stay was not medically necessary onward, and the patient could have been managed adequately at a lower level of care. The patient had failed outpatient antibiotics given orally and presented with progressive cellulitis and X-ray that showed soft tissue swelling throughout the lower extremity. Intravenous antibiotic administration and admission was appropriate to ensure administration of intravenous antibiotics and to confirm that the patient was responding well to treatment before a plan for discharge was made. Admission was medically appropriate. By the end of day #4, the patient had responded adequately to treatment and evaluation showed that she was not developing any new problems or issues to require continued inpatient stay. The patient was able to take oral intake, was afebrile, and had stable vital signs. The patient had responded adequately to treatment by the end of day #4. Therefore, the requested health service was partially medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System /other 
Treatment: Inpatient hospital 
The insurer denied part of the hospital stay 
The denial is partially overturned 

The patient with past medical history of coronary artery disease, mitral regurgitation, and celiac disease who presented to emergency department (ED) with complaints of pleuritic chest pain and shortness of breath. Vitals signs were stable. The patient's chest imaging revealed right mid lateral lung consolidation with differential diagnosis of community acquired pneumonia or Tuberculosis.

Yes, the hospitalization is medically necessary in part.

The patient had a chest tube still in place Multiple subacute rehabilitation facilities refused to accept him in transfer due to presence of chest tube and Heimlich in place. He was not accepted at any of the local subacute rehab centers. The chest tube which was cautiously removed despite the presence of pneumothorax on CXR. There was reasonable and appropriate concern for worsening of pneumothorax because of history of prior worsening/ recurrence and close follow up and hospital monitoring was reasonable and clinically indicated. Pneumothorax was noted to be stable despite slightly increased shortness of breath as reported by patient. Based on available documentation, he could have been safely discharged to subacute rehab.

Since his pneumothorax remained stable, physician team removed chest tube. Considering the patient had a stable but persistent pneumothorax now with multiple previous re-expansion of pneumothoraxes requiring recurrent chest tube place prior in the stay - the standard of care and prudence is towards monitoring him for stability in the hospital with follow up CXR which was done in this case. Once the pneumothorax was stable for 48-72 hours, a discharge could have been considered safely despite need of low amount of oxygen.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing teeth
Treatment: Implants For Teeth 2, 13, 14, 15, 30 and 31
The insurer denied the Implants For Teeth 2, 13, 14, 15, 30 and 31.
The denial is partially overturned.

This patient is a female requesting six implants be placed rather than wearing partial dentures. The denial was because there was no documentation indicating a reason why implants are the only viable treatment for this patient. The provider then sent a letter stating that the patient could not tolerate a partial denture because of difficulty in eating and speaking. She also had a strong gag reflex with a denture in place. These were the reasons why implants would be needed, instead of a denture.

Yes, in part; the proposed implants 30 and 31 are medically necessary. However, the proposed implants 2, 13, 14 and 15 are not medically necessary.
This patient it stated to have difficulty in eating and speaking with dentures in place.  In addition, she is stated to have a strong gag reflex with a denture in place.  

There is enough bone for placement of implants in the areas of teeth 30 and 31. This would give the patient two more teeth to chew with on the right side.
Placement of implants for teeth numbers 2, 13, 14 and 15 are not possible due to the maxillary sinus being in the way. There is not enough bone in these areas for the implants to be placed.

Yes, in part; the Health plan acted reasonably for teeth 2, 13, 14 and 15 as the implants are not medically necessary for these teeth. However, the Health plan did not act reasonably for teeth 30 and 31 as the implants are medically necessary for these teeth.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neck Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is partial approved. 

The patient is a male with cervical syrinx and C6 (sixth cervical spine vertebra) ependymoma status post multiple cervical surgeries and syringo-pleural shunt, as well as multiple other medical problems. The patient has chronic paresthesias in all extremities.

The patient presented to the ED (emergency department) and was admitted. MRI (magnetic resonance imaging) was performed, which showed no new findings in the cervical spine. Patient had IV (intravenous) antibiotics and had his oral pain medications increased.

Yes, in part. The Inpatient admission was medically necessary, in part. 

The patient presented with severe pain that required IV (intravenous) pain medications. Therefore, the initial dates are medically necessary for acute inpatient level of care, as the patient required IV (intravenous) pain medications and had severe pain that could not be controlled in a lower level of care. In addition, the patient had workup for known cervical lesion with multiple consults to specialties. As such, these dates are medically necessary. The remainder of the dates are not medically necessary, because there were no treatments provided and no issues encountered that would warrant acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Jaw Fracture

Treatment: hospital admission

The insurer denied coverage for hospital admission.

The denial is modified.

This patient suffered a jaw fracture that required treatment. The patient was in a motor vehicle accident (MVA), and suffered a left mandibular angle fracture, which was determined that the patient would need an open reduction internal fixation (ORIF) performed. The patient left against medical advice and was given a prescription for antibiotic, which he did not fill, and then returned four days later, and was admitted for ORIF. The patient was then scheduled to be treated in the hospital setting and undergo general anesthesia with nasal intubation for open reduction and internal fixation. This is an appeal for inpatient overnight hospitalization. The patient also had tooth 17 removed along with a cyst. The patient was discharged.

"With the exception of the nose, mandibular fractures occur twice as frequently as fracture of other facial bones. The importance of the mandible is not only cosmetic; it also functions in biting, chewing, and speaking."1

"The purpose of the treatment of mandibular fractures is to restore proper dental occlusion and stable temporomandibular joint (TMJ) movement as well as the reduction of the displaced fracture."2

"The ability to treat fracture with open reduction (OR) and internal fixation (IF) has dramatically revolutionized the approach to mandible fracture.3 Traditionally, OR/IF has required a period of postoperative mandibular immobilization by rigid maxillomandibular fixation (MMF) for up to 6 weeks for satisfactory healing. Difficulties associated with this period of immobilization include airway problems, poor nutrition, weight loss, poor mouth hygiene, phonation difficulties, insomnia, social inconvenience, patient discomfort, work loss, and difficult in recovering normal-range jaw function. Rigid fixation of mandible fractures allows early mobilization and restoration of jaw function and airway control; improves nutritional status, speech, oral hygiene, and patient comfort; and allows early return to the workplace.4 5" (El-Anwar et al 2015).

The patient required an extensive surgery to include open reduction and internal fixation of a left angle fracture as well as removal of tooth 17 with cyst removal. The patient was nasally intubated under general anesthesia. The surgeon recommended the patient be kept overnight to make sure there were no airway issues as well as pain control, nutritional status and hemostasis were under control.      

Based on the clinical information provided the patient should have been allowed an overnight stay for the day of surgery for one day. This allowed the patient to be followed for airway patency, swelling, fluid status, pain control, nausea and vomiting, and hemostasis. The first two days of admission the records do not support why the patient was in the hospital, or why the surgery was not performed on a given date.

Based on the above, the medical necessity for the hospital admission is partially substantiated. The insurer's denial is modified.