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

This is a patient who was admitted due to depression and suicidal ideation with a plan to hang himself in the context of an argument with his mother. The patient has a history of attention deficit hyperactivity disorder (ADHD) and pseudoseizures. The patient has no previous hospitalizations. The patient has attempted suicide in the past. The patient was noted to have chronic suicidal ideation since the age of 10 which intensifies with interpersonal conflict. The patient was calm and cooperative. He denied suicidal ideation at this time. The patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations. The patient was not physically aggressive, acutely manic or sexually inappropriate. The patient was not catatonic. The patient had no significant medical instabilities. The patient had no required emergency medications, restraints or seclusions. He was working on coping skills. The patient remained a chronic ongoing risk of impulsive behavior, even at the time of discharge. The health plan's determination is overturned in part. The patient did have suicidal ideation with a plan, a history of suicide attempts and was in an environment of stress and interpersonal conflict with his mother. Therefore, evaluation at an inpatient level of care on was appropriate for 1 day, however, after that treatment at a lower level of care was reasonable and in the best interest of the patient to treatment him at the least restrictive environment.  
The patient did have suicidal ideation with a plan, a history of suicide attempts and was in an environment of stress and interpersonal conflict with mom. Therefore, 24 hour evaluation at an inpatient level of care  was appropriate and medically necessary.
However, after that, the patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations. The patient was not physically aggressive, acutely manic or sexually inappropriate. The patient was not catatonic. He had no significant medical instabilities. The patient had no required emergency medications, restraints or seclusions. The interpersonal conflict was chronic and not acute. Treatment could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary heart disease, hypertension, gastroesophageal reflux disease (GERD), hyperlipidemia.

Treatment: personal care aide (PCA) level 2: 6 hours per day - 7 days per week - for a total of 42 hours per week.

The insurer denied coverage for personal care aide (PCA) level 2: 6 hours per day - 7 days per week - for a total of 42 hours per week.

The denial is modified.

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as "modified independent."  She requires extensive assistance for bathing, lower body dressing, bed mobility, and toilet transfers.  Limited assistance is needed for toilet use.  She is frequently incontinent in her bladder and continent of the bowel.  She is independent with personal hygiene, upper body dressing, and eating.  She requires supervision for ambulation.  According to her treating nurse practitioner's note, she has normal lower extremity strength, and her gait was documented as normal.  

The combination of the patient's medical condition and functional impairments support the medical necessity of the Personal Care Aide Services of 5 hours/day, 7 days/week for a total of 35 hours/week; allowing the ability to continue living safely and independently at home.  The requested personal care aide (PCA) Level 2: 6 hours/day - 7 days/week - for a total of 42 hours/week is not medically necessary.  

From a physical medicine and rehabilitation perspective, PCA level 2: 6 hours/day - 7 days/week - for a total of 42 hours/week is not medically necessary.  However, PCA level 2: 5 hours/day - 7 days/week - for a total of 35 hours/week is medically necessary.  

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 personal care aide (PCA) Level 2: 6 hours per day - 7 days per week - for a total of 42 hours per week is modified. Medical Necessity for Personal Care Aide Services of 5 hours/day, 7 days/week for a total of 35 hours/week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Epigastric pain, change in mental status
Treatment: Continued Inpatient Hospital Admission
The insurer denied the Continued Inpatient Hospital Admission
The denial is overturned, in part.

The patient is a male who has a history of scleroderma. The patient was followed by a rheumatologist. The patient presented with epigastric pain. The patient also evidenced a change in mental status and was intubated and maintained on a ventilator. There was a concern for aspiration pneumonia. 

The patient's medical history was significant for systemic scleroderma, lupus complicated by end-stage renal disease on dialysis via left upper extremity arteriovenous (AV) fistula, personality disorder with previous psychiatric hospitalizations, and opioid abuse disorder.  He was initially admitted for abdominal pain and missed hemodialysis sessions. The hospital course was complicated by computed tomography (CT) imaging showing intra-abdominal fluid collection with concern for possible abscess, and left renal hematoma. Surgery and interventional radiology (IR) were consulted but there was no indication for drainage. The patient had not received antibiotics. A rapid response was called for altered mental status and concern for seizure activity in the setting of hypoglycemia.  The patient was transferred to the medical intensive care unit (ICU) for video electroencephalography (EEG) monitoring and was started on Depakote.  The patient was also noted to have a presenting hemoglobin of 6.6.

Yes, in part; the inpatient admission was medically necessary for the last 27 days of the admission; however, inpatient admission was not medically necessary for the first 21 days of admission. 
The initial admission was due to the profound anemia and electrolyte disturbances. The patient was focused on his pain. Non-compliance was a hallmark of this period of care.  The patient was stabilized.  The first 21 days of the admission did not require acute inpatient admission and was not medically necessary as the patient was stable.

However, the patient evidenced seizure activity in the setting of hypoglycemia. He was intubated and transferred to an intensive care unit setting. The patient had further altered mental status (AMS) (requiring intubation, self extubation), sepsis, methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia, aspiration pneumonia (PNA), anemia (requiring multiple transfusions likely due to chronic kidney disease [CKD]), candidemia (blood culture [BCx] likely intraabdominal source) and imaging with interval development of two new abscesses in mid lower abdomen (not amendable to drainage) and possible proctocolitis.  The patient was on 10% dextrose (D10) for refractory hypoglycemia.  

The patient was then transferred out of intensive care unit (ICU); however, around nine minutes into hemodialysis (HD), he had a change in mental status and seizure like activity. He was rescreened into the medical intensive care unit (MICU), placed on bi-level positive airway pressure (BIPAP) and weaned to nasal canula (NC).