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

Diagnosis: Syncope.

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is modified. 

This case involves a patient who presented to the Emergency Department (ED) due to syncope and loss of consciousness. The documentation indicated the patient has a history of protein C and S deficiency. The documentation also detailed the patient has a positive history that includes diabetes as well as hypertension, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and atrial fibrillation (A. fib).  The physical examination revealed the patient was alert and oriented.  The patient had 99% oxygenation on room air.  A normal sinus rhythm was noted per EKG (electrocardiogram).  The physician detailed the patient should undergo diagnostic and laboratory studies.  A computed tomography (CT) scan of the head revealed no acute findings. The physician indicated the patient was re-observed multiple times while in the ED.  It was recommended that the patient be admitted for further evaluation due to syncope.  The documentation indicated the patient was recommended to undergo consultation by cardiology as well as neurology for further treatment recommendation.  The patient continued with treatment and no further significant abnormalities.  It was recommended that this patient undergo a tilt table test as well as the possibility of an implantable loop recorder.  The patient however refused tilt table testing.  Throughout the stay the patient also refused orthostatic vital signs as well as monitoring with telemetry.  The documentation indicated the patient subsequently developed a rash where he was given intravenous (IV) diphenhydramine.  The following day the patient declined further treatment and signed out against medical advice (AMA).

 The submitted documentation indicated the patient presented with multiple complaints with a history of a-fib with hypertension, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD).  The documentation indicated the patient was admitted due to the need for close monitoring and further observation.  The initial hospital day was medically indicated, however the patient did not have any further adverse events and remained stable the remainder of the time.  Therefore, the remainder of the admission was not medically necessary. The health plan acted reasonably in part.

The insurer's denial of coverage for the emergent hospital admission is modified.  Medical Necessity is substantiated for first inpatient day, but is not substantiated for the remainder of the inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and dementia.
Treatment is an increase PCW 24 hours a day live-in, 7 days per week.
The insurer denied coverage for an increase PCW 24 hours a day live-in, 7 days per week.
The denial is modified.

This is a patient with chronic medical problems including osteoarthritis, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and dementia. She lives alone in a 1-bedroom apartment. The insurer approved PCW (personal care worker) for 8 hours/day, 7 days/weeks totaling 56 hours/week and she is requesting an increase in PCW 24 hours a day live-in, 7 days per week.

According to the Uniform Assessment System (UAS) report the patient's cognition is described as "moderately impaired;" which has declined over the prior 90 days. She requires extensive assistance for bathing, upper body dressing and toilet use. Limited assistance is required for personal hygiene, upper body dressing, ambulation (with a cane) and toilet transfers. The patient is frequently incontinent of bladder and continent of bowel. She is independent for bed mobility and eating. The combination of the patient's cognitive deficits and functional impairments support the medical necessity of increasing PCW to 12 hours/day, 7 days/week for a total of 84 hours/week. Her condition and functional needs are not at a level or unpredictable as to require the requested PCW 24 hours a day live-in, 7 days per week. This physician would agree the patient may require additional monitoring. However, safety monitoring (e.g., dementia) 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 enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by the increasing PCW to 12 hours/day, 7 days/week for a total of 84 hours/week.

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.

From a physical medicine and rehabilitation perspective, the requested PCW 24 hours a day live-in, 7 days per week is not medically necessary. However, increasing PCW 12 hours/day, 7 days/week totaling 84 hours is medically necessary.

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 Worker (PCW) 24 hours a day live-in, 7 days per week services is not substantiated. However, increasing PCW to 12 hours/day, 7 days/week for a total of 84 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dizziness/Vertigo
Treatment: Inpatient Hospital Stay
The health plan denied: Inpatient Hospital Stay
The determination is: Partially overturned

The patient is a female with past medical history (PMH) of diabetes mellitus type 2 (DM2), rheumatoid arthritis (RA), and hypothyroidism who was admitted with complaints of syncope after suffering profuse diarrhea. The patient previously had a complicated hospital stay due to left ankle abscess complicated by lumbar 5 - sacral 1 (L5-S1) discitis and methicillin-resistant staphylococcus aureus (MRSA) bacteremia and was on prolonged antibiotics. Her vital signs were notable for a blood pressure (BP) of 93/64 millimeters of mercury (mmHg) and a pulse of 117 beats per minute (bpm). The physical exam was notable for abdominal tenderness to palpation (TTP). The lab work was notable for a white blood cell (WBC) count of 3.5. The patient was diagnosed with dehydration secondary to Clostridium difficile (C. diff) diarrhea and was treated with intravenous fluids (IVF) and oral vancomycin. The patient was discharged on 12/16/2022 in stable condition. At issue is the medical necessity of the inpatient hospital stay.
The health plan's determination of medical necessity is overturned in part.
In part, the requested health service/treatment of inpatient hospital stay was medically necessary for this patient. This patient presented to the emergency department (ED) after a syncopal episode associated with profuse diarrhea, prolonged antibiotic exposure, and sepsis with hypotension. With appropriate work-up, the patient was found to have severe dehydration secondary to clostridium difficile infection. Clostridium difficile colitis requires close observation for hypotension, hematochezia, signs of sepsis or toxicity, intractable vomiting, severe electrolyte abnormalities, and altered mental status, especially in a patient with severe dehydration and sepsis. This complex patient with diabetes and severe dehydration required close clinical monitoring and aggressive management that could not have been safely provided at an alternate level of care, given the hemodynamic instability. However, after 5 days, the patient is documented to have no diarrhea, vital signs had stabilized, and infectious disease signed off, and beginning on this date the patient could have been safely and appropriately treated at an alternate level of care. It is noted that the patient had an issue with insurance authorization, which likely contributed to the patient's prolonged hospital stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease, Lymphedema. 
Treatment: Personal care services (PCS) 8-10 hours per day, 7 days a week for a total of 56-70 hours per week. 
The insurer denied coverage for personal care services (PCS) 8-10 hours per day, 7 days a week for a total of 56-70 hours per week. 
The denial is modified. 

The patient is currently authorized for 42 hours a week. The patient has a medical history of Parkinson's disease, urinary frequency, and lymphedema. The patient lives in the independent section of a facility. The patient has some tremors when their medications wear off. The patient has had hyponatremia. The patient's primary care note indicates no falls, ability to get out of bed to toilet once at night. The patient receives Botox injections for foot dystonia. The patient has difficulty with donning their compression socks. The patient has rotator cuff syndrome. The patient does exercise, yoga and physical therapy (PT) at their facility. The patient needs help with preparing meals, housekeeping, laundry, shopping, transferring, bathing, dressing, toileting, medication management, personal hygiene, and eating. 

The patient has mild cognitive impairment. The patient has a medical history of Parkinson's disease, urinary frequency, and lymphedema. The patient needs assistance with her activities of daily living (ADLs). 

The patient has some tremors when their medications wear off. The patient has difficulty with donning her compression socks. The patient has rotator cuff syndrome. The patient needs help with preparing meals, housekeeping, laundry, shopping, transferring, bathing, dressing, toileting, medication management, personal hygiene, and eating. In this case, personal care services are medically necessary. Approval is for 56 PCS hours per week. 

"The activities of daily living (ADLs) is a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. The term activities of daily living was first coined by Sidney Katz in 1950. ADL is used as an indicator of a person's functional status. The inability to perform ADLs results in the dependence of other individuals and/or mechanical devices. The inability to accomplish essential activities of daily living may lead to unsafe conditions and poor quality of life. Measurement of an individual's ADL is important as these are predictors of admission to nursing homes, need for alternative living arrangements, hospitalization, and use of paid home care. The outcome of a treatment program can also be assessed by reviewing a patient's ADLs" (1). 

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 services (PCS) 8-10 hours per day, 7 days a week for a total of 56-70 hours per week services is not substantiated. However, 56 hours of PCS is medically supported.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abscess.
Treatment: D2750 Crown - Porcelain Fused to High Noble Metal, Tooth #8 and D3310 Endodontic Therapy Anterior Tooth (excluding final restoration), Tooth #8.
The insurer denied the D2750 Crown - Porcelain Fused to High Noble Metal, Tooth #8 and D3310 Endodontic Therapy Anterior Tooth (excluding final restoration), Tooth #8.
The denial is overturned, in part.

The patient is a female.  Tooth #8 has a two-surface (mesio-lingual) composite restoration present. The tooth also has a periapical radiolucency (abscess) at the end of the root.

Yes, in part; the root canal treatment, code D3310, was medically necessary.  However, the crown, code D2750, was not medically necessary.
The tooth had an infection (abscess) that required a root canal procedure to correct the problem. 

Since there was no new decay in the tooth that required any drilling out of the existing conservative filling, there was still sufficient tooth structure present after the root canal procedure was done. Therefore, in this case, a crown was not necessary to restore the tooth. The patient stated that the tooth became darker, but that is an aesthetic issue, not a functional one.  The crown is not medically necessary.

Yes, in part;  the health plan acted reasonably, with sound medical judgment and in the best interest of the patient in denying the crown; however, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient in denying the root canal as it was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: type I diabetes, heart failure, legal blindness.

Treatment: Consumer-directed personal assistance services (CDPAS), a total of unspecified hours per week

The insurer denied coverage for consumer-directed personal assistance services (CDPAS), a total of unspecified hours per week.

The denial is modified.
 

This case pertains to an adult male who lives alone. He has a diagnosis of anxiety, depression, type I diabetes, heart failure, legal blindness, hypertension, gastroesophageal reflux disease, hypercholesterolemia, insomnia, and constipation. Medications include Amlodipine, Aspirin, Atorvastatin, Atropine, Bupropion, Carvedilol, Docusate, Hydrochlorothiazide, Lantus, Losartan, Melatonin, Omeprazole, Trazadone and Vitamin D2. 

The patient requested help with meal preparation, cleaning, medications, and doctor's visits due to legal blindness in both eyes. He had an overnight hospitalization when he underwent bariatric surgery. He is cognitively intact. He requires maximal assistance with meal preparation, housework, managing finances, and shopping. He requires extensive assistance with transportation. He requires supervision with managing medications, stairs, and ambulation. He utilizes a walking cane. His aide provides set-up assistance for bathing, and clothing set up. 

The tasking tool noted the need for 7.48 hours per week of personal assistance. The review of the assessment found that the patient requires set-up help with bathing, toileting, eating, and dressing. The tool notes those tasks as independent and does not assign any time to them. He noted in the assessment that due to his blindness; his aid sets out clothes, sets up his bath items and toileting items, and sets his food out. She also sets up his medications. These small tasks were allotted 5 minutes each. The meal preparation was only allotted 5 minutes per meal. This was increased to 30 minutes per meal. The new total hour for the week is 16.25 hours per week. The decision is overturned, and he is approved for 16 hours per week. Considering the assessment and allotted times for tasks in the tool, this patient should receive 16 hours per week of consumer-directed personal assistance service.

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 consumer-directed personal assistance services (CDPAS), a total of 16 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Dependence

Treatment: Inpatient substance detoxification Admission

The insurer denied the Inpatient Admission. The denial was modified: Approved for specific days and denied for specific days.

This is a middle aged female who was admitted to inpatient substance detoxification treatment in early 2019. She was noted to have been drinking four 24 once beers per day. She had a history of alcohol dependence, nicotine dependence, inpatient detoxification treatment, and hypertension. Her withdrawal symptoms included trouble sleeping, anxiety, joint pain, tremors, and sweating. Her Clinical Institute Withdrawal Assessment for Alcohol (CIWA) Scale and Clinical Opiate Withdrawal Scale (COWS) scores were 8.  During her admission she was treated with Librium detoxification protocol.  She reportedly lacked coping skills for sobriety and the ability to identify relapse triggers. The patient successfully completed detoxification and was discharged. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  In this case this patient still had reports of alcohol withdrawal symptoms and required and received continued Librium detoxification medication to modify withdrawal and prevent severe, complicated, or life threatening withdrawal then so she required continued inpatient detoxification treatment.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) she did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as she continued to use alcohol despite past inpatient detoxification treatment,  and needed she detoxification medication to modify withdrawal and needed 24 hour treatment then as she was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including severe and life threatening withdrawal symptoms.

The carrier's denial of coverage for inpatient hospital services is modified. Approved for specific days and denied for specific days.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sinus pressure.
Treatment: Functional Endoscopic Sinus Surgery.
The insurer denied the Functional Endoscopic Sinus Surgery.
The denial is overturned, in part. 

The patient is a female. Evaluation indicates sinus pressure worse on the left side, prior treatment with nasal sprays, antihistamines, and amoxicillin. Examination with endoscopy indicates deviated nasal septum, congested nasal lining, left polypoid lesion and hypertrophy inferior turbinates. Sinus CT (computed tomography) scan report states moderate opacification left ethmoid air cells and left frontoethmoidal recess, mucosal thickening left maxillary sinus, narrow left ostiomeatal unit due to mucosal thickening, mucosal thickening of the right frontoethmoidal recess, right maxillary sinus clear, sphenoid sinuses clear, right ostiomeatal unit patent, nasal septal deviation to the right. Diagnosis is chronic sinusitis. Review is for Functional Endoscopic Sinus Surgery.

The health plan's reason for denial is imaging scan does not show disease in all the requested sinuses (frontal, sphenoid, or maxillary). Appeal is for approval of Functional Endoscopic Sinus Surgery procedures.

The requested health service is medically necessary, in part.

Specifically, the requested treatment Functional Endoscopic Sinus Surgery for the frontal and maxillary sinuses is medically necessary, and the requested treatment Functional Endoscopic Sinus Surgery for the sphenoid sinuses cannot be confirmed as medically necessary.

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

Functional Endoscopic Sinus Surgery for the frontal and maxillary sinuses are medically necessary, and Functional Endoscopic Sinus Surgery for the sphenoid sinuses is not medically necessary.

The prior denial states imaging scan does not show disease in all the requested sinuses (frontal, sphenoid, and maxillary). However, CT scan report states opacification left ethmoid air cells and left frontal ethmoid recesses, mucosal thickening left maxillary sinus, narrow left ostiomeatal unit due to mucosal thickening, mucosal thickening right frontoethmoidal recess, right maxillary sinus clear, sphenoid sinuses clear, right ostiomeatal unit patent, nasal septal deviation to the right.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gunshot wound
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is partially overturned.

This patient is a male who presented to the emergency department (ED) as a priority 1 trauma patient following an incident in which he was shot in the back/buttock. He had been hypotensive during the period of pre-hospital transport to the hospital.
The ED trauma evaluation included a computed tomography (CT) scan that identified retroperitoneal bleeding and a possible right external iliac vein injury and possible intra-abdominal injury to the rectosigmoid colon.
Trauma and vascular surgery consultations were obtained. A second CT scan with rectal contrast was performed and showed stability in the size of the retroperitoneal hematoma and no evidence for rectal injury. Based on the mechanism of injury and the imaging findings, the surgical service recommended a diagnostic laparoscopy to assess for an intra-abdominal bowel injury.
A diagnostic laparoscopy was performed. There was no apparent intra-peritoneal penetration or injury. He was monitored in the trauma intensive care unit (ICU) following surgery. A duplex ultrasound showed no deep vein thrombosis and was a normal study. The patient was transferred out of the ICU to the surgical floor. He was without new complaints. He was provided a regular diet. He was started on oral anticoagulation with Eliquis.The patient was discharged from the hospital with arrangements for vascular surgery follow up.
At issue is the medical necessity of an inpatient stay.

The inpatient stay was medically necessary in part. The first 2 days of the stay were medically necessary, then the patient could have been discharged. The Milliman Care Guidelines (MCG) Multiple Trauma 26th edition state that hospital admission is indicated when a patient with significant multiple trauma requires inpatient admission for major surgical and postprocedural care or nonoperative care of significant injury.
This was a patient who sustained a gunshot wound to the back/buttock that required emergent evaluation for a potentially significant vascular injury. Additionally, he required emergent surgery to definitively assess for intra-abdominal injury from the GSW. He required the coordinated care of multiple surgical (Trauma, Vascular Surgery) and ancillary disciplines to optimize his care and outcome. He required assessment and re-assessment consistent with trauma guidelines to guide the care and treatment provided. The intensity of service provided for the first 2 days of the stay and the consequences of missed vascular or intra-peritoneal injury did warrant an inpatient designation during this time. His condition and the mechanism of injury, based on the results of the initial vital signs and CT scan, carried high risk for acute decompensation.