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

Diagnosis: Abdominal Pain (Crohn's disease)
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned, in part.

The patient is a female with Crohn's on oral steroids and Stelara who presented with abdominal pain, weakness and vomiting. She was tachycardic in the emergency room (ER), which improved with hydration. Computed tomography (CT) revealed active Crohn's, without obstruction. She was placed on intravenous steroids. 

Day two, the patient's symptoms were noted to be improved on intravenous steroids. There was no significant vomiting, and she tolerated oral intake, and her diet was being advanced. The plan was to discharge her on oral steroids on day three. 

Day three, the patient tolerated a solid breakfast and was moving her bowels, but later in the day started experiencing vomiting and abdominal pain after each meal.  She was placed on intravenous (IV) steroids again. 

Day four, the patient's diet was again advanced on intravenous (IV) steroids, but she still had pain requiring pain medication. 

Day five, the patient felt much improved, tolerated a diet without pain, and she was discharged on prednisone.

Yes, in part; the proposed treatment, inpatient admission, was medically necessary for last three dates of service .  However, inpatient admission for first two dates of service was not medically necessary.
As the patient was hemodynamically stable, without evidence of sepsis, dehydration, electrolyte abnormalities, intractable vomiting, inability to tolerate oral intake, toxic megacolon or a need for surgical intervention, or gastrointestinal (GI) bleeding, acute inpatient stay was not medically necessary on the first two dates of service. Care could have been provided at a lower level of care. 

However, while the patient was improved and medically stable for discharge, she had recurrent abdominal pain and vomiting requiring re-induction of intravenous steroids.  Therefore, acute inpatient hospital stay was medically necessary for the remaining dates of service.

Yes, in part; the health plan did act reasonably, with sound medical judgment and in the best interest of the patient in denying the first two dates of service  as they were not medically necessary; however, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient in denying the last three dates of service as they were medically necessary.
As acute inpatient was medically necessary for the last three dates of service.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizoaffective Disorder, psychotic symptoms, depressive symptoms, suicidal ideation with a plan
Treatment: Inpatient admission, medication management

The insurer denied the continued inpatient mental health services. The denial was modified (partially approved - one of 5 days was allowed)

This patient was brought in by ambulance to the Emergency Room (ER) for an emergency psychiatric evaluation. He reportedly had command auditory hallucinations telling him to hurt himself, had depressed mood, feelings of hopelessness, helplessness, and worthlessness, and had self-injurious behavior by cutting himself with a razor.  He was non-compliant with medications.  He was using crack/cocaine.  He had past suicide attempts and multiple past psychiatric hospitalizations.  He had a reported diagnosis of Schizoaffective Disorder.  He was unemployed and had limited education.  He reportedly had Abilify Maintena IM, started Clozapine and it was increased.  He was discharged.

The insurer denied stated that his mood was stable, he denied thoughts of self-harm or hallucinations, and had no acute symptoms requiring continued hospital treatment.  

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia report that patients with hallucinations, delusional thinking, disorganized thinking or behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior, or inability to adequately care for basic needs are candidates for hospitalization.  

In this case this patient still had psychotic symptoms including internal preoccupation, and the notes also reported that he was ambivalent in suicidality, was isolative, not interactive, and was smiling inappropriately.  He had reports of command auditory hallucinations on admission with self-injurious behavior, depressed mood, feelings of hopelessness, helplessness, and worthlessness on admission with crack/cocaine use so he was considered at risk if still experiencing psychotic symptoms and not ready for discharge yet.  That was the case on first day denied as he still had psychotic symptoms of responding to internal preoccupation.  He had a reported history of multiple past psychiatric hospitalizations and had medication changes including adding and increasing Clozapine and also took Abilify Maintena IM also so he had an active psychiatric treatment plan.  However, as of second day of the denial period there were no further reports of psychotic symptoms, severe depressive symptoms, or suicidal ideation, plan or intent.  There were no reports of specific identifiable or quantifiable treatment goals or objectives that could only have been achieved in a 24 hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting at that time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infertility
Treatment: IVF (in vitro fertilization), ICSI (intracytoplasmic sperm injection), and PGT-A (preimplantation genetic testing for aneuploidies)
The insurer denied the IVF, ICSI, and PGT-A.
The denial is overturned, in part.

The patient is a female with a diagnosis of infertility due to decreased ovarian reserve and a male factor. She has failed three prior IUI (intrauterine insemination) cycles.

The provider plans to proceed with in vitro fertilization (IVF). However if the patient does not develop an adequate number of follicles, the IVF cycle will be converted to an insemination cycle.

The request is for IVF, ICSI (intracytoplasmic sperm injection) and PGT-A (preimplantation genetic testing for aneuploidies).

The requested health service is medically necessary, in part.

This patient has a diagnosis of infertility and has failed three insemination cycles. The next step is to proceed with IVF. While the patient has decreased ovarian reserve with decreased odds of conception, because of her young age, her odds of conception and live birth are still acceptable (greater than 5% [percent]).

Note that ICSI is warranted due to the presence of a male factor. Note, however, that PGT-A is not medically necessary as the patient is not documented to be the carrier of any chromosomal anomaly or genetic condition with the risk of passing it to a fetus.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, in part.

The health plan erred in denying IVF and ICSI. However, the decision to deny PGT-A was reasonable and within the standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Fever/Wheezing.
Treatment:  Inpatient stay.
The insurer denied the inpatient stay.  The health plan's determination is overturned in part.  The first two days of the inpatient stay were medically necessary. 

The patient is a boy brought by ambulance to the emergency department (ED) with fever for two days and wheezing since the morning.  He received racemic epinephrine and solumedrol en route to the ED with Emergency Medical Services (EMS).  At triage, He was noted to have stridor, but was otherwise well appearing to the triage RN.  Temperature was 101.7, heart rate (HR) 139, respiratory rate (RR) 25, blood pressure (BP) 103/53, and oxygen saturation 99% on room air.  He was admitted to the hospital.

The inpatient stay for 2 days was medically necessary.  This previously healthy boy presented with fever, respiratory distress and signs and symptoms of upper airway obstruction from infectious cause (stridor, croupy cough, posterior pharyngeal erythema, radiographic soft tissue swelling, pus seen in trachea by ENT on scope).  His influenza swab was positive for Influenza B and given the pus seen on scope, the treating providers reasonably concluded that he had a bacterial superinfection of the trachea.  He did not have hypoxemia, but did have significant respiratory distress documented.  Bacterial tracheitis is a potentially serious infection, even life threatening, if not managed promptly and properly with antibiotics (e.g. ceftriaxone and vancomycin as in this case), anti-inflammatories (steroids given in this case), upper airway dilators (e.g. racemic epinephrine inhalation treatments) and, if necessary, advanced airway management up to and including mechanical ventilation.  He did not have hypoxemia or severe and progressive distress; his disease responded to the initial therapies in the ED and PICU: antibiotics, antiviral, steroids, racemic epinephrine, heliox.  On the first hospital day, the trajectory of his illness was uncertain, and it was appropriate that he be managed in a setting that could not only treat his condition as it was, but also rescue his airway if he worsened.  So, the first hospital day was medically necessary.  

By the second hospital day, he had improved significantly.  It was reasonable to continue the intravenous antibiotics until his blood cultures were negative at 48 hours.  On this day, the heliox and racemic epinephrine were stopped and he began to eat.  By the middle of the second hospital day, further care was medically necessary in the form of IV antibiotics, and the inpatient stay on this day was indicated.

The third hospital day was not medically necessary.  By hospital day three, he was drinking and eating, breathing comfortably without any respiratory distress or hypoxemia, and off IV antibiotics because his cultures were negatives at 48 hours.  He could have been safely discharged home on oral antibiotics and not have spent another night in the hospital.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart disease, chronic kidney disease (CKD), hypertension, gastroesophageal reflux disease (GERD). 

Treatment: Personal care services 12 hours per day, 7 days per week, totaling 84 hours per week. 

The insurer denied coverage for personal care services 12 hours per day, 7 days per week, totaling 84 hours per week. 

The denial is modified. 

This is a patient with chronic medical problems including heart disease, chronic kidney disease (CKD), migraines, obstructive sleep apnea (OSA), ulcerative colitis (UC), atrial fibrillation and osteoarthritis.  She lives in a 4-bedroom apartment on the 3rd floor of a building with an elevator.  The plan approved personal care services (PCS) 6 hours a day (4 days a week), 7 hours a day (2 days a week) and 2 hours a day (1 day a week), totaling 40 hours/week.  Under review is the medical necessity for personal care services 12 hours per day, 7 days per week, totaling 84 hours per week. 

According to the Uniform Assessment System (UAS) report, the patient's cognitive ability is described as "minimally impaired."  She requires extensive to maximal assistance for dressing, personal hygiene and toilet transfer/use.  She is incontinent of bladder (uses straight catheter every 2 hours) and has an ostomy for bowel management.  Her cognitive and functional impairments do not support the medical necessity of the requested 12 hours per day, 7 days per week, totaling 84 hours per week.  However, increasing PCS to a more consistent 7 days x 7 hours (49 hours/week) is clinically appropriate and medically necessary in order to allow her to continue living safely at home. 

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based). 

From a physical medicine and rehabilitation perspective, personal care services 12 hours per day, 7 days per week, totaling 84 hours per week is not medically necessary.  However, increasing PCS to a more consistent 7 days x 7 hours (49 hours/week) is clinically appropriate and 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 personal care services 12 hours per day, 7 days per week, totaling 84 hours per week is modified. Medical Necessity is substantiated for 7 days x 7 hours (49 hours/week).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing Teeth
Treatment: Endosteal Implant, Teeth #s 2, 3, 5, 6, 7, 13, 14, 15, 18, 19, 20, 21, 30,
and 31

The insurer denied the Endosteal Implant, Teeth #s 2, 3, 5, 6, 7, 13, 14, 15, 18, 19,
20, 21, 30, and 31.
The denial is overturned, in part.

The patient is a female who has multiple missing teeth in the upper and lower jaws. The request is for multiple implants to be placed.

The denial was due to there being no reason(s) given why removable prosthetics
(i.e. full or partial upper denture and a partial lower denture) cannot be used.

Yes, in part; the proposed implants are medically necessary for teeth #s 3, 5, 6, 7,
13, 14, 18, 20, 21, and 30. However, the proposed treatment for teeth #s 2, 15, 19,
and 31 are not medically necessary.
The patient has been stated as being unable to wear dentures. The patient cannot
chew food properly the way the teeth are, with the teeth that are missing. The
provider wants to place implants in the following positions: 2, 3, 5, 6, 7, 13, 14, 15,
18, 19, 20, 21, 30 and 31.

This is far too many implants. Many people chew and survive very well with only
one molar in a quadrant; there is no reason to place implants on the patient's right
side in the areas of teeth 2 (upper right) and 31 (lower right). These would be
second molars, and they are not needed. Not having them would in no way
compromise the patient's eating ability.

Also, there is no need for an implant where tooth #15 is, since there already is a
viable tooth there. On the lower left, there is no need for an implant for tooth #19,
since an implant supported bridge can be placed on the implants #18 and #20.

The fewer implants that need to be placed, the better for this patient. There will be less implants to heal, less complications and the chewing ability without these four implants (#'s 2, 15, 19 and 31) will not be compromised at all.

No, in part; the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient as implants for teeth #s 3, 5, 6, 7, 13, 14, 18, 20, 21, and 30 were medically necessary. However, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient as teeth #s 2, 15, 19, and 31 are not medically necessary.

There is information supporting some of the requested implants; however, some of the requested implants are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hypertension, heart disease and diabetes.

Treatment: personal care aide (PCA) services 7 days per week, 12 hours per day (84 hours per week).

The insurer denied coverage for personal care aide (PCA) services 7 days per week, 12 hours per day (84 hours per week).

The denial is modified.

 
This is an elderly patient with hypertension, heart disease and diabetes.  She lives with her spouse in a private residence.  The insurer approved personal care aide (PCA) 5 hours/day, 7 days/week, total 35 hours/week and the request is for 12 hours/day, 7 days/week, total 84 hours/week.   

According to the Uniform Assessment System (UAS) report the patient's cognition is minimally impaired.  She has the capacity to properly activate a Personal Emergency Response System (PERS) unit and can call Emergency Medical Services (EMS) if necessary.  She is reportedly totally dependent for much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  

The patient reportedly requires extensive assistance for bathing, lower body dressing, locomotion, ambulation, and toilet transfer/use.  Limited assistance is reportedly needed for personal hygiene and upper body dressing.  She is reportedly independent with eating and bed mobility.  The patient is frequently incontinent of bladder and continent of bowel.  There has been no reported decline in her ability to perform activities of daily living (ADL) tasks over the past 90 days.  However, she has fallen on 1 occasion over the past 90 days and evaluated in the hospital emergency department.  

The patient's clinical and functional deficits are not at a level and unpredictable as to require the requested PCA 84 hours/week.  However, her clinical condition and limited functional ability supports PCA 70 hours/week.  This physician is persuaded by the letters from the patient's treating physician describing her upper extremity impairments including the tremors and lymphedema.   This physician would also agree that given the patient's reported general weakness and debility, she may benefit from additional safety monitoring.  However, safety monitoring under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.   Based on the records reviewed, the patient's health and safety can be appropriately provided and maintained by increasing PCA to 10 hours/day, 7 days/week, total 70 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) services 7 days per week, 12 hours per day (84 hours per week) services is not substantiated. However, PCA services 10 hours/day, 7 days/week, total 70 hours/week are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia, Asthma Exacerbation.

Treatment: Inpatient Admission.

The insurer denied the inpatient admission.

The denial was modified.

This is a male patient with medical history of asthma, pneumonia, hypertension and smoking cigarettes. He presented to the hospital with complaints of chest pain, weakness, and productive cough with yellow brown sputum, shortness of breath, and vomiting. His vital signs at presentation were: temperature 98.6 F, heart rate 84, respiratory rate 18, blood pressure 131/84, and oxygen (O2) saturations 97 %. The patient's lung exam revealed decreased breath sound and some wheezing; the patient's cardiac exam was within normal limits (WNL). The patient had a white blood cell (WBC) count as high18K during his hospitalization. The patient's chest x-ray and computed tomography (CT) scan revealed bilateral patchy, multilobar infiltrates; negative for a pulmonary embolism (PE). The patient was admitted to the hospital for treatment of multilobar pneumonia, asthma exacerbation, and acute kidney injury (AKI). He received intravenous (IV) fluids, (IV) steroids, and IV antibiotics; Vancomycin, Aztreonam and Doxycycline. 

A few days into the patient's admission, the patient had started feeling better. The patient was afebrile and hemodynamically (HD) stable. The patient's oxygen saturation was 98 % on nasal cannula, and the patient's lungs were clear to exam; the patient's wheezing had improved. The patient's culture and sensitivity were negative. The differential diagnosis of myocardial infarction was ruled out. The patient was tolerating oral intake, and his cough had improved. The patient could have been switched to oral steroids and antibiotics, and the patient could have been continued treatment regimen at home with close follow-up as outpatient. Thus, while admission for the first few days was medically necessary, continued inpatient stay for the last several days was not medically necessary for this patient.

The health plan acted reasonably with sound judgment to deny coverage for continued inpatient stay for the first several, but did not act in the best interest of the patient to deny coverage for inpatient admission for the last few days. 

Based on the above, the medical necessity for the inpatient admission from is partially substantiated.  The insurer's denial should be modified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Flank Pain.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay. The determination is overturned in part.

The patient presented to the hospital with complaints of flank pain. Past medical history significant for sarcoidosis, lower urinary tract symptoms (LUTS), nephrolithiasis and hypertension. On presentation, he endorsed undergoing a right ureteroscopy 2 days prior to admission. During the procedure, a mid ureteral stricture was encountered and a ureteral stent was placed. There were no associated symptoms. On presentation, he was afebrile and hemodynamically stable. Lab results were grossly normal. Creatinine was 12.0 and the white blood cell count (WBC) was 17. A computed tomography (CT) scan demonstrated a migrated right ureteral stent with the distal coil at the ureterovesical junction (UVJ). A small pelvic fluid collection consistent with extravasation was noted. Extravasated urine was also seen in the right retroperitoneal cavity. He was admitted to the inpatient service and managed with intravenous antibiotics, a Foley catheter and intravenous (IV) fluids. The cultures were negative.  At issue is the medical necessity of an inpatient stay.

The inpatient stay was medically necessary in part. A majority of patients who present with renal colic can be discharged within 48 hours of the presentation. This patient did not present with hemodynamic instability, severe renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control.
However, the patient was noted to be febrile.  His temperature was reported to be 102.2 degrees Fahrenheit on the third day.  His white blood cell count (WBC) count was lower than at presentation.  As such, continued monitoring for another 24 hours would have been appropriate.  The patient could have been discharged earlier in the stay. He could have been treated at a lower level of care for the first 2 days and then inpatient for the next 2 days.  Discharge was appropriate when the patient was afebrile for 24 hours. He was continued on antibiotics and he had another low-grade temperature (101.4 degrees).