Persius/imr-appeals huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Elective oocyte cryopreservation. 
Treatment: Leuprolide, Ganirelix, Follistim, and Menopur. 

The insurer denied: Leuprolide, Ganirelix, Follistim, and Menopur. 
The denial is partially overturned. 

The patient is an adult female who consulted with a reproductive endocrinologist for elective oocyte cryopreservation (OC). The patient reports that she has an increased lifetime risk of breast cancer as the indication for oocyte cryopreservation. Injectable fertility medications Lupron, ganirelix, Menopur and Follistim have been prescribed. The Health Plan has denied coverage of the service due to the lack of meeting coverage criteria.

The health plan should cover the proposed Lupron, ganirelix, and Menopur.  However, the health plan should not cover the proposed Follistim. 

The medical records and medical literature were thoroughly reviewed. The American Society for Reproductive Medicine, in its Practice Committee Opinion, states: "In recent years, the use of OC has greatly expanded not only for women facing gonadotoxic treatments but also for other indications, such as delaying childbearing, as well as for the purpose of oocyte donation." Therefore the service of Lupron, ganirelix, and Menopur is within the standard of care. 

However, there is no evidence that Follistim is more effective for ovarian stimulation than the formulary medication Gonal-F and there has been no evidence presented in the medical records that it is or has been ineffective or has adverse effects for this patient. Therefore there is no support in the peer-reviewed literature or as standard of care that Follistim is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing teeth
Treatment:  D5214 Partial Lower Denture, D2791 All Metal Crown, Tooth 15 and D2791 All Metal Crown, Tooth 14
Decision: Partially Overturned

Summary:
The patient is a female requesting dental benefit for single crowns on teeth #'s 14 and 15, and a lower partial denture.

The patient is missing teeth on both sides of her lower jaw, so replacing them with a partial denture would help her chew. Therefore, the request for a lower partial denture, code D5214 is medically necessary.

The crowns on teeth #'s 14 and 15 are not needed according to the x-rays sent. First of all, tooth #14 is part of an existing bridge, so placing a single crown on it is impossible. There is no decay seen on the x-rays, so replacing the bridge (if that is what was meant) is not needed. Tooth #15 does not exhibit any decay or fracturing, so there is no need for a crown at this time based on the limited information provided. The crowns are therefore not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute vaso-occlusive sickle cell crisis 

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is modified

This is the case of a female with sickle cell anemia with a history of acute chest of multiple pulmonary embolisms related to Lovenox therapy, and a history of cerebral vascular accident (CVA). The patient was admitted with right hip, right leg, and back pain. In the emergency department (ED), the patient received multiple doses of intravenous (IV) Dilaudid. Upon serial monitoring, the patient continued to have uncontrolled pain. She was admitted to inpatient care. The patient received IV pain medications, IV fluids, and a hematology evaluation. Once the patient clinically stabilized, and was ruled out for acute chest syndrome, she was discharged 

"The pathophysiology, clinical presentation, and natural history of acute pain in sickle cell disease are unique and require a disease-centered approach that also applies general principles of acute and chronic pain management. The majority of acute pain episodes are managed at home without the need to access health care. The long-term consequences of poorly treated acute pain include chronic pain, adverse effects of chronic opioid usage, psychological maladjustment, poor quality of life, and excessive health care utilization. There is no standard protocol for management of an acute pain crisis in either the hospital or the community. The assumptions that severe acute pain must be managed in the hospital with parenteral opioids and that strong opioids are needed for home management of pain need to be questioned. Pain management in the emergency department often does not meet acceptable standards, while chronic use of strong opioids is likely to result in opioid-induced hyperalgesia, exacerbation of chronic pain symptoms, and opioid dependency. We suggest that an integrated approach is needed to control the underlying condition, modify psychological responses, optimize social support, and ensure that health care services provide safe, effective, and prompt treatment of acute pain and appropriate management of chronic pain. This integrated approach should begin at an early age and continue through the adolescent, transition, and adult phases of the care model." (Telfer, P., & Kaya, B. 2017)

However, the note from the ED says that there is no suspicion for chest syndrome, so that is not a reason for admission. Hematology advised changing Dilaudid to intramuscular (IM) or oral, and tapering. The patient was still in pain. Assessment of a plan of care says that she is okay to go home tomorrow. Subsequent day notes not provided. 

The health care plan acted reasonably in part.

The inpatient hospital admission is partially substantiated. Approve coverage for the first day and deny coverage for continuous admission.  

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

Diagnosis:  Cervical radiculopathy, discectomy and fusion
 
Treatment:  Inpatient admission, monitoring

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

This case involves a male with cervical and lumbar radiculopathy, hypertension, thoracic aortic aneurysm with repair, gastroesophageal reflux disease (GERD), neuropathy, and benign prostatic hyperplasia.  He had a body mass index 31.0 - 31.9.  The patient presented for a scheduled anterior cervical discectomy, decompression, and fusion of C5-C6 and C6-C7.  He had an American Society of Anesthesiologists Class III classification.  The patient had numbness and tingling in both arms and pain in his neck.  He underwent surgical intervention and was admitted post-operatively.  There were no complications noted.  A progress note from the next day noted the patient's finger numbness and pain had improved.  He remained stable the following day and had full motor strength.  He required a straight catheterization overnight and was referred to urology as an outpatient to address urinary retention issues that existed before surgery and persisted after surgery.

Milliman Care Guidelines indicate a cervical anterior discectomy and fusion would generally be performed on an ambulatory basis.  Criteria for ambulatory surgery indicate ambulatory surgery would be appropriate for a 1 or 2 level fusion at or below C3 without myelopathy and without the need for more than 24 hours postoperative observation.  An inpatient stay would be appropriate for a patient who is elderly, who undergoes a multilevel fusion with 3 or more levels, or for patients requiring extended postoperative observation with unstable comorbidities.  The goal length of stay would be one day. 

This patient underwent an anterior cervical discectomy and fusion at C5-6 and C6-7 with plate fixation at 3 levels, C5, C6, and C7.  This would be considered a 3-level fusion.  The patient did not have myelopathy, and the surgery was performed below C3. Although the patient's classification was ASA Class III, the surgical procedure would have been considered low risk, as it was an ambulatory surgery.

Based on the above, the medical necessity for the inpatient hospital admission is modified.  The first day is approved; the remainder of the stay is denied.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infected nerves. 
Treatment: D2750 White glass with high gold content crown for teeth 10, 19, 3, 2, 15, 31, 9; 
D3330 Nerve treatment on molar tooth for teeth 19, 3, 2, 15 and 31; 
D6750 White glass with high gold content cap for bridge for teeth 4, 29, 31, 13, 6, 11; 
D6240 False tooth for bridge for teeth 30, 5 and 12; 
D3310 Nerve treatment on front tooth for teeth 9 and 10; 
D3320 Nerve treatment on bicuspid tooth for teeth 4 and 13. 

The health plan denied D2750 White glass with high gold content crown for teeth 10, 19, 3, 2, 15, 31, 9; D3330 Nerve treatment on molar tooth for teeth 19, 3, 2, 15 and 31; D6750 White glass with high gold content cap for bridge for teeth 4, 29, 31, 13, 6, 11; D6240 False tooth for bridge for teeth 30, 5 and 12; D3310 Nerve treatment on front tooth for teeth 9 and 10; D3320 Nerve treatment on bicuspid tooth for teeth 4 and 13. 

The denial is partially overturned. 

The patient is an adult female needing multiple root canal treatments as well as multiple crowns and bridges. The health plan denied coverage as not medically necessary. The denial is being appealed. 

Specifically, crowns on teeth numbers 2, 10, and 19; root canal treatments for teeth numbers 2, 4, 9, 10, 13, 19, and 31; bridge 4, 5, 6 with #5 false tooth; bridge 11, 12, 13 with #12 being a false tooth, bridge 29, 30 and 31 with #30 being a false tooth are medically necessary. Also, a bridge on 4, 5, and 6 means that caps/crowns on #4 and #6, are medically necessary; a bridge on 11, 12 and 13 means a caps/crowns on 11 and 13 are medically necessary; and a bridge on 29, 30 and 31 means caps/crowns on 29 and 31 are medically necessary. 

Single crowns for teeth #s 2, 10 and 19 are coded D2750. Crowns that are part of a bridge, i.e., teeth 4, 6, 11, 13, 29 and 31 are coded D6750. False crowns that are part of a bridge, teeth 5, 12 and 30 are coded D6240. 

Root canal treatment for teeth numbers 3 and 15 are not evidenced by the provided x-rays to be medically necessary. Crowns on teeth numbers 3, 9 and 15 are not evidenced by the provided x-rays to be medically necessary. Additionally, because Tooth 31 is to be used as a part of a bridge, a crown coded as D2750 would not be medically necessary, since it is being approved under the requested D6750 code. 

There are multiple teeth that have infected nerves. These are the teeth that need the root canal treatment. Most of the teeth needing root canals will need a crown (except #9). All these teeth need to be treated instead of extracting them. Extractions are not needed when the tooth can be treated. There are not evidenced to be any teeth that are hopeless and need extraction. The bridges are needed to replace missing teeth and to allow this patient to chew with a complete dentition. The bridges will also prevent further tooth movements (i.e. tilting). 

All of the requested treatment is needed and medically necessary except for the crowns on 3, 9 and 15 (not needed) and root canals on 3 and 15 (not needed).
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 partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia and rheumatoid arthritis
Treatment: Personal Care Aide (PCA) services for a total of 126 hours per week
The insurer denied coverage for Personal Care Aide (PCA) services for a total of 126 hours per week.
The denial is modified.

This is a patient with diagnoses that include dementia and rheumatoid arthritis. She lives with her spouse who is supportive and involved in her care. She is currently approved for Personal Care Aide (PCA) level 2: 6 hours/day- 7 days/week - for a total of 42 hours per week, and the request is for PCA Level 2: 6 hours/day- 7 days/week; 12 hours/day- 7 days//week for a total of 126 hours/week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as severely impaired. She is totally dependent for performing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She requires maximal assistance for bathing, dressing, bed mobility, ambulation (uses a walker) and toilet transfer/use. Extensive assistance is needed for personal hygiene and eating. The patient is frequently incontinent of bladder and occasionally incontinent of bowel. Her functional ability is much the same when compared to the previous UAS report. The patient's condition and functional needs are not at a level, unpredictable or significantly declining as to require the requested PCA 126 hours/week. This physician would agree the patient may require additional monitoring, particularly due to her nighttime wandering. However, safety monitoring under a PCA does not include monitoring an individual (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 are more appropriately provided and maintained by increasing PCA services to 12 hours/day, 7 days/week, totaling 84 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: 12 hours per day- 7 days per week for a total of 84 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: myocardial infarction
Treatment: Life Vest - Four (4) Month Rental 
The insurer denied Life Vest - Four (4) Month Rental. The health plan's determination is overturned in part. The Life Vest is medically necessary for 3 months.  

The patient is a man with a history of hypertension and diabetes who presented to the hospital complaining of dyspnea. He was diagnosed with a non-ST segment elevation myocardial infarction and congestive heart failure. Cardiac catheterization showed severe three vessel disease. By echocardiogram, his left ventricular ejection fraction (LVEF) was 25-29%. The patient underwent coronary artery bypass graft surgery. He was started on guideline-directed medical therapy for heart failure with reduced ejection fraction; he did not tolerate a beta-blocker. An echocardiogram showed an LVEF of 26-30%. He was discharged with a LifeVest wearable cardioverter defibrillator (WCD).

The Use of the LifeVest for three months was medically necessary. In a retrospective evaluation of 4958 patients with LVEFs of 35% or less after coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) from two combined databases, 809 patients who were discharged with a WCD were compared to the remaining 4149 patients. The WCD was associated with a lower 90-day mortality in patients after CABG (no WCD: 7% vs WCD: 3%) and after PCI (no WCD: 10% vs WCD: 2%). In the Wearit II registry, which included 805 patients with ischemic cardiomyopathy, the rate of potential life-threatening ventricular tachyarrhythmias was 3% over a 3 month period. All episodes that were treated by the WCD were successfully terminated, suggesting that these patients had aborted sudden death versus actual sudden death. The 2016 American Heart Association Science Advisory considers use of the WCD reasonable during the "waiting period" following myocardial infarction or revascularization, as does the 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. However, after 90 days, this patient would have been eligible for an implanted device if his LVEF remained 35% or less, unless there was a medical reason for further delay. The records provided do not document that there was such a reason. Therefore, continued use of the WCD after 3 months was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypoglycemia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is modified

This is a patient born via repeat cesarean section at 39.1 weeks gestation, birth weight 2400 grams. Apgar scores were 8 and 9 at one and five minutes respectively. Initial care was in the Well Newborn Nursery. Glucose screening was undertaken due to Small for Gestational Age (SGA).  The glucose was 56 milligrams (mg)/deciliters (dL) and subsequently was 57 mg/dL. The 52 mg/dL.  However, the glucose was 45 mg/dL at 21 hours-old, followed by 43 mg/dL, and then, at 46 hours-old, the point of care testing (POCT) Glucose was 34 mg/dL on an exclusive demand breast feeding schedule. There was documentation of associated poor feeding and fatigue. The patient was diagnosed with neonatal hypoglycemia and transferred to the Neonatal Intensive Care Unit (NICU) for further management - ad lib feeds at breast and supplemental formula with continued monitoring and possible need for intravenous (IV) glucose. The following afternoon, the POCT glucose was 79 mg/dL (post-feeds). Subsequently, POCT glucoses were as follows: 70 mg/dL, 85 mg/dL, 64 mg/dL, and 79 mg/dL. Also, a basic metabolic panel had a glucose of 107 mg/dL. The patient was discharged the following day.
 
This infant was at risk for neonatal hypoglycemia by virtue of being SGA. Initial care was in well newborn with normal glucoses until approximately 21 hours-old when the POCT glucose was 43 mg/dL. Inexplicably, another POCT glucose was not done until 25 hours later when it was only 34 mg/dL. There was no confirmation of hypoglycemia by a serum glucose (done in the laboratory). Thereafter, all POCT glucoses were greater than 60 mg/dL which is the nadir for normal neonatal glucose after 48 hours of age. Assuming the POCT glucose of 34 mg/dL was an accurate reflection of the serum glucose, transfer to the NICU for continuous cardiorespiratory monitoring and further management of "hypoglycemia" was a reasonable undertaking at a Neonatal Facility, Level II per Milliman Care Guidelines (MCG): LOC-005. Also, it was in accord with MCG: P-595, Newborn Care, Term, with Severe Illness or Abnormality wherein "higher-level neonatal care (i.e., other than Level 1 nursery) for neonate whose gestational age is 37/07 weeks or greater is indicated by: Hypoglycemia."   

In view of the above, the denial for NICU level of care is upheld for days one, two and four and reversed only for day three.

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 the full hospital neonatal intensive care unit (NICU) admission is modified. Reverse denial for day three of admission.
Appeal type: Medical necessity
Decision: Overturned

The patient had diagnoses of schizophrenia (SCZ) and Cannabis / synthetic cannabis or marijuana (K2) Use Disorder (CUD).  On admission to the hospital, he was noted to symptoms of disorganized behavior, loud speaking to self, making nonsensical comments, and showing poor insight and judgment.  The health plan's determination of medical necessity is overturned in part.  The patient on evaluation after being brought in by EMS was sufficiently disorganized and admission was necessary to do a diagnostic assessment as to what caused the patient's behaviors that had required police intervention on the day of admission.  Therefore, a partial inpatient hospital stay was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted teeth
Treatment: Surgical Extraction (D9243 IV (intravenous) Sedation each 15 minute; D7240 Extraction of Impacted Tooth Covered by Bone Tooth, 16, D7240 Extraction Impacted Tooth Covered by Bone, Tooth 1, D9243 IV Sedation each 15 Minutes; D7240 
Extraction of Impacted Tooth Covered by bone, Tooth 1; D720 Extraction of Impacted Tooth Covered by Bone, Tooth 16; D9243 IV Sedation each 15 minutes x 2)
The insurer denied: Surgical Extraction (D9243 IV (intravenous) Sedation each 15 minute; D7240 Extraction of Impacted Tooth Covered by Bone Tooth, 16, D7240 Extraction Impacted Tooth Covered by Bone, Tooth 1, D9243 IV Sedation each 15 Minutes; D7240 Extraction of Impacted Tooth Covered by bone, Tooth 1; D720 Extraction of Impacted Tooth Covered by Bone, Tooth 16; D9243 IV Sedation each 15 minutes x 2)
The denial is Partially Overturned.

The patient is a teenage male. He presented for evaluation for extraction of his third molars. Upon examination, the patient has impacted teeth #1, 16, 17, 18, 31, and 32. The provider requested extraction of teeth #1, 16, 17, and 32, and surgical access of impacted teeth #18 and 31 with intravenous sedation. The plan approved extraction of teeth #17 and 32 with 40 minutes of intravenous sedation. According to the denial letter, teeth #1 and 16 were denied because, according to the plan, in order for the tooth to be extracted, the tooth must have severe pain or must be in a position that will not let it break through the gum by itself. The plan also denied the additional units of intravenous sedation. The denial is being appealed.

The requested health service is medically necessary, in part.

Code D7240 for teeth #1 and #16 is indicated. Based on AAOMS (American Association of Oral and Maxillofacial Surgeons) recommendations, "When removal of an impacted tooth is 
indicated, it is surgically prudent and cost beneficial that other impacted teeth be considered for treatment at the same surgical session. This reduces the need for additional anesthetic and 
surgical procedures." Thus, extraction of teeth #1 and 16 is indicated. As for IV (intravenous) sedation (D9243 x1), 1 unit total of 15 minutes is indicated in this case.