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


Diagnosis: Childbirth
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned in part (3 additional days are medically necessary).

This patient presented to the hospital for scheduled repeat cesarean delivery. The patient was a female who presented at 37-0/7 weeks gestation. The patient denied contractions, vaginal bleeding or leakage of fluid. She reported that the baby was moving as was usual. She had prenatal care with a total of 10 visits. Her previous history was noted for a term cesarean, a preterm 23 week delivery with classical cesarean delivery (a preterm delivery in that case was 23-24 week twins), and then the current pregnancy. The patient was being delivered early as she had a previous history of classical cesarean delivery. At presentation, the patient was alert and oriented and without any complaints. The patient was noted to have an estimated fetal weight of 2200 g (grams) and cephalic presentation. Amniotic fluid index was normal and fetal heartbeat was present. The placenta was posterior. The patient was admitted for a planned repeat cesarean delivery. Her placental evaluation had been noted for no evidence of accreta. The patient was admitted to labor and delivery for planned delivery. She had routine admission labs and intravenous (IV) fluid hydration. She was at risk for postpartum hemorrhage and a moderate risk was noted resulting in a type and hold for blood being sent. Pain management was planned. The patient was to have venadines for deep vein thrombosis (DVT) prophylaxis.

The inpatient stay was medically necessary for 3 additional days. From this point forward, the inpatient stay was not medically necessary.
Based upon a review of the medical records in this case and the complex presentation of the patient and patient care in the setting of a spontaneous uterine rupture at cesarean with occult, delayed presentation of maternal bladder injury leading to large volume ascites in the maternal peritoneal compartment, the inpatient stay was medically necessary for the additional days.
For the following dates, there was no ongoing need for acute inpatient level of care given the patient had recovered from surgery. Placement of Nexplaneon is an outpatient procedure and not an indication for admission to acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizophrenia. 
Treatment: Behavioral Health Inpatient Services. 
The health plan denied Behavioral Health Inpatient Services. The health plan's determination is overturned in part. Six additional days of Behavioral Health Inpatient Services are medically necessary. 

The patient is a male with diagnoses of chronic schizophrenia (SCZ), Cannabis Use D/O (CUD), and Ecstasy Use Disorder (EUD). He has required multiple psychiatric admissions. He has been non-adherent to his medication. The admission under review was initiated via emergency services due to the patient's violence and aggression toward his family (father and sister). 

Six additional days are medically necessary for several reasons. This patient's SCZ is severe, chronic, and functionally impairing. His form of SCZ is of a very severe type, marked by prominent negative symptoms, and less responsive to medications. Additionally, his use of two substances made his treatment more complex. The patient was not able to tolerate the daily interview of the mental status but walked out of the room. He would not engage in attempts at group therapy. He was still disheveled. He had minimal spontaneous speech. He showed thought blocking and poverty of thoughts. He was illogical and appeared to be internally preoccupied. He reported no suicidal or homicidal ideation. He was not behaviorally aggressive. He denied hallucinations or delusions. He had no side effects from his medications. While he was very functionally impaired, he appeared to have reached his baseline state of functioning. His mood was good. 
While he was still substantially impaired by his negative symptoms on day 5, he appears to have returned to his baseline state. There was no evidence predictive of violence. He had no suicidal ideation. He has no positive psychotic features. Therefore, he could be discharged on day 6 with good medical judgment, in accord with current standards of best care, and in accord with the medical literature. While his actual discharge appeared to be delayed beyond day 6 due to his family declining to take him back home, this was not a medical reason for continued BHIS.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Ureteral calculus with hydronephrosis.
Treatment:  Inpatient Hospital Stay.

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

This is a female patient who was admitted with left renal colic and fevers. She had a history of hypertension and diabetes. Her vital signs were temperature 98.3 degrees Fahrenheit, blood pressure (BP) 126/82 and pulse 92. The white blood cell count (WBC) count was 10,000. The urinalysis had large leukocyte esterase and white blood cells (WBCs). The creatinine was 1.2. Computed tomography (CT) imaging demonstrated a 14 x 5 millimeter (mm) left proximal ureteral calculus with hydronephrosis. Intravenous (IV) pain medications, nausea medications, IV antibiotics and intravenous fluids (IVF) were administered. On the same day, interventional radiology placed a percutaneous nephrostomy tube. She received IV antibiotics. She was afebrile. The WBC count was 9000 and the creatinine was 1.0. She was discharged home after 5 days. She was afebrile and hemodynamically stable throughout the stay. At issue is the medical necessity of an inpatient stay.

An acute inpatient level of care was medically necessary/appropriate in part. The patient had an obstructing stone associated with pyelonephritis. She required urgent drainage for a potentially life-threatening condition. By the second day of the stay, she was improved and medically stable. She was adequately drained and on appropriate antibiotics. The care could have been provided at a lower level of care.

The determination is overturned in part. An acute inpatient level of care was appropriate for the first 2 days of the stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, hypothyroid, osteoarthritis, anemia

Treatment: Consumer directed personal assistance services (CDPAS) 7 days per week, 24 hours per day, 168 hours per week services

The insurer denied coverage for CDPAS 7 days per week, 24 hours per day, 168 hours per week services

The denial is modified

This is a geriatric patient with chronic medical problems including dementia, hypothyroid, osteoarthritis and anemia. The patient lives alone in a private residence. The insurer approved CDPAS 4 hours per day, 7 days per week for a total of 28 hours per week and the request is for CDPAS 24 hours per day, 7 days per week for a total of 168 hours per week. 

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognition was described as "minimally impaired." The patient is totally dependent for much of the Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework, and shopping. The patient requires extensive assistance for bathing and lower body dressing. Otherwise only limited assistance is needed for personal hygiene, upper body dressing, locomotion, ambulation, eating and toilet transfer and use. The patient is occasionally incontinent of bladder and continent of bowel. The patient is independent with bed mobility. There have been no falls over the prior 90 days. When compared to the previous UAS report, the patient's functional ability has only modestly declined. The patient's condition and functional needs are not at a level or unpredictable as to require the requested CDPAS 24 hours/day, 7 days/week. Based on the records reviewed, the patient's health and safety can be more appropriately provided and maintained at home with an increased CDPAS 8 hours/day, 7 days/week for a total of 56 hours/week. This physician would agree that the patient may require additional monitoring. However, safety monitoring under Personal Care Services (PCS) does not include monitoring an individual (with dementia) when no other Level I or Level II personal care services tasks are being provided. 

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, CDPAS, 24 hours/day (continuous care by more than 1 person) is not medically necessary. However, increasing CDPAS to 8 hours/day, 7 days/week (total 56 hours/week) is medically necessary. 

Based on the above, the insurer's denial must be modified. The health care plan acted reasonably in part. The medical necessity for CDPAS 7 days per week, 24 hours per day, 168 hours per week services is not substantiated. However, CDPAS of 8 hours/day, 7 days/week (total 56 hours/week) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Heart Attack/Non-ST Elevation Myocardial Infarction (NSTEMI). 
Treatment: Durable Medical Equipment (DME) including wearable defibrillators/3 Month Rental of K0606-RR - LifeVest (Wearable Automatic Cardiac Defibrillator). 

The health plan denied the requested 3 Month Rental of K0606-RR - LifeVest (Wearable Automatic Cardiac Defibrillator) as not medically necessary. The health plan's determination is partially overturned. 

This man presented to the emergency department complaining of chest pain. His medical history was remarkable for hypertension, diabetes, obesity and hyperlipidemia. His serum troponin level was elevated. A cardiac catheterization showed no obstructive disease; however, the distal left anterior descending coronary artery (LAD) was small. Left ventriculogram showed a left ventricular ejection fraction (LVEF) of 30-35% with an apical wall motion abnormality. The patient was thought to have Takotsubo cardiomyopathy; dissection of the distal LAD could not be ruled out. An echocardiogram was performed and was consistent with Takotsubo cardiomyopathy. The patient was treated with guideline directed medical therapy for heart failure with a reduced ejection fraction. He was discharged with a LifeVest wearable cardioverter defibrillator (WCD). A repeat echocardiogram showed improved left ventricular systolic function and the WCD was discontinued. Per the information provided, the device was returned. 
At issue is the medical necessity for the 3 Month Rental of K0606-RR - LifeVest (Wearable Automatic Cardiac Defibrillator). 

I overturn, in part, the determination that the use of the WCD for the first 2 months was medically necessary. I uphold the determination that it was not medically necessary for a third month. 

Based on the documentation provided, the use of the wearable cardioverter defibrillator for the first 2 months was medically necessary. Use of the device for a third month was not medically necessary. 

This patient presented to the hospital with chest pain and was found to have a markedly reduced left ventricular ejection fraction, most likely due to Takotsubo cardiomyopathy. Depressed left ventricular systolic function is a risk factor for, and a powerful predictor of sudden arrhythmic death. Consequently, implantation of an implantable cardioverter defibrillator (ICD) for the primary prevention of sudden cardiac death is a widespread practice, proven to be beneficial to heart failure patients with a variety of cardiac diagnoses. Current guidelines support ICD implantation in patients, such as this man, with nonischemic cardiomyopathy and left ventricular ejection fractions of 35% or less. However, due to the possibility that left ventricular function may improve with time and/or treatment, it is recommended that device implantation be delayed for at least 90 days following the initial diagnosis of nonischemic cardiomyopathy and initiation of therapy. If, after 90 days of optimal medical therapy, the LVEF remains less than or equal to 35%, ICD implantation is then recommended.
Appeal type: Medical necessity
Decision: Overturned

The patient is a male, who had presented to the emergency department for evaluation of cough, wheezing, subjective fever, and chills. He was tachypneic, afebrile, hemodynamically stable, and had normal room air oxygen saturation. Physical examination was significant for mild tachypnea, ability to speak full sentences, and bilateral expiratory wheezes. Chest x-ray was negative for acute cardiopulmonary process. There was some improvement in the patient's symptoms with emergency department treatment. However, persistence of exertion dyspnea was noted, prompting admission for management of asthma exacerbation.

Treatment included systemic glucocorticoid and inhaled bronchodilators. There was improvement in the patient's clinical symptoms and peak expiratory flow rate (PEFR). He was transitioned from intravenous to oral glucocorticoid per pulmonologist recommendation and was discharged.

The patient was readmitted following presentation to the emergency department for evaluation of shortness of breath, cough, and post tussive vomiting following dust inhalation at work. He had been compliant with prednisone prescribed at discharge. There was mild tachypnea and tachycardia. He was afebrile and room air oxygen saturation was normal. Chest auscultation was significant for bilateral wheezes. Review of laboratory data was significant for leukocytosis with a left shift. Chest x-ray was unremarkable. The patient improved with systemic glucocorticoid and inhaled bronchodilators. He was discharged.

The health plan's determination is overturned, in part.

No, the inpatient stay was not medically necessary for the first admission.

The patient presented with asthma exacerbation. There was rapid improvement in PEFR following admission. There was no hemodynamic instability, hypoxia, hypercapnia, respiratory distress, altered mental status, need for ventilatory support, associated pneumonia, presence of risk factors for asthma-related death, or concern for poor adherence with asthma medication following discharge. The patient continued to improve and was discharged. Documentation does not support inpatient level of care. The patient could have been adequately managed at a lower level of care.  
Yes, the inpatient stay was medically necessary for the second admission. 

The patient was at risk for asthma death due to recent hospitalization for asthma exacerbation and ongoing use of oral corticosteroid. Aggressive treatment at inpatient level of care with intravenous glucocorticoid and inhaled bronchodilators, as well as close monitoring of response to therapy was appropriate in this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Screening Chromosomal Anomalies.

Treatment genetic testing (81220 x1, 81329 x 1, 81243 x 1) diagnostic testing.

The insurer denied coverage for genetic testing (81220 x1, 81329 x 1, 81243 x 1) diagnostic testing.

The denial is modified.

The patient has no significant medical history. The provider ordered carrier screening for cystic fibrosis (CF), Fragile X and spinal muscular atrophy (SMA). There is no documentation that the patient has a personal or family history of inherited genetic disorders. 

As per the American College of Obstetricians and Gynecologists (ACOG), "All patients who are considering pregnancy or are already pregnant, regardless of screening strategy and ethnicity, should be offered carrier screening for cystic fibrosis (81220) and spinal muscular atrophy SMA (81329). All other genetic carrier screening in the absence of a positive family history or personal history and in the absence of an ethnic background at high risk for these conditions is considered not medically necessary". ACOG based their recommendation on the fact that there is insufficient scientific evidence that the requested gene panel will have a significant impact on treatment planning or outcome. 

Current consensus guidelines from professional genetics organizations recommend carrier screening only for women with a family history of fragile X syndrome or undiagnosed mental retardation, developmental delay, or autism or for those with ovarian insufficiency. 

The American College of Obstetricians and Gynecologists Committee on Genetics recommends testing for fragile X syndrome as follows: 

Women with a family history of fragile X-related disorders, unexplained mental retardation or developmental delay, autism, or premature ovarian insufficiency are candidates for genetic counseling and fragile X premutation carrier screening. 

If a woman has ovarian insufficiency or failure or an elevated follicle-stimulating hormone level before certain age without a known cause, fragile X carrier screening should be considered to determine whether she has an FMR1 (fragile X mental retardation 1) premutation. 

This patient does not have any of the above conditions. Testing for Fragile X (81243) was not medically necessary. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

Genetic testing (81220 x1, 81329 x) diagnostic testing is considered medically necessary for this patient. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for genetic testing (81220 x1, 81329 x 1, 81243 x 1) diagnostic testing is modified. Approve genetic testing (81220 and 81329) but uphold denial of 81243.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Nasal Obstruction and Sinus Symptoms.
Treatment:  CPT (current procedural terminology) Code - 30465 [Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction)], CPT Code - 31253 [Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed], and CPT Code - 30465 [Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction)].

The insurer denied CPT Code - 30465 [Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction)], CPT Code - 31253 [Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed], and CPT Code - 30465 [Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction)].  The denial is partially overturned.

The patient is an adult male with a history of chronic nasal obstruction and chronic sinusitis. There is a history of previous nasal and sinus surgery. Exam reports a deviated septum with inferior turbinate hypertrophy and nasal valve pathology. Bilateral polyps are also noted. Medical therapy has included nasal and oral steroids, antibiotics and montelukast. Sinus computed tomography reported pansinus disease. The provider is requesting coverage of CPTs (current procedural terminologies) 30465, 30465 and 31253. The request was previously denied, and the provider is appealing the denial.

The requested health service is medically necessary. However, CPT (current procedural terminology) 30465 is a bilateral CPT (current procedural terminology) so only one 30465 is allowable. 

There is a history of chronic sinusitis and nasal obstruction. There is a history of previous nasal and sinus surgery. Exam reports a deviated septum with inferior turbinate hypertrophy and nasal valve pathology. Bilateral polyps are also noted. Medical 
therapy has included nasal and oral steroids, antibiotics, and montelukast. Symptoms remain. Sinus computed tomography reported pansinus disease. There are patient photos provided that document internal nasal valve pathology. Based on the 
above, with the documented pathology on exam, computed tomography, photos, and the failure of medical therapy, the medical necessity of the CPTs (current procedural terminologies) 30465 (one), 31253 would be confirmed. The requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 Diabetes Mellitus, hypertension, memory loss, cervical/lumbar radiculopathy, osteoarthritis, urinary incontinence

Treatment: Increase in Personal Care Worker (PCW) services from 7 days per week, 7 hours per day, 49 hours per week to 12 hours per day, 84 (hrs)hours per week.

The insurer denied coverage for an increase in Personal Care Worker (PCW) services from 7 days per week, 7 hours per day, 49 hours per week to 12 hours per day, 84 hours per week

The denial is modified

This patient is a female with multiple medical problems including diabetic neuropathy, atrial fibrillation and hypertension. The insurer approved a PCW increase from 7 hours/day (49 hours/week) to 8 hours/day (56 hours/week). Under review is the request for an increase in PCW services to 12 hours/day (84 hours/week). 
 
According to the Uniform Assessment System (UAS) report, the patient is modified independent with making decisions and has appropriate short-term memory that has not changed over the prior 90 days. She can direct her own care and activate a personal emergency response system in case of an emergency. However, her functional status has declined; particularly with activities of daily living (ADL). She requires extensive to maximal assistance for bathing personal hygiene and dressing. She requires limited assistance for toilet transfer and extensive assistance for toilet use. She is frequently incontinent of bladder and infrequently of bowel. She has vision and hearing deficits that also continue to decline. The PCW hours were increased to 7 days per week, 8 hours per day: 56 hours per week.  However, increasing PCW to 10 hours/day (70 hours/week) is a more reasonable clinical decision in order to allow the patient to continue living safely at home.   
 
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 an increase in Personal Care Worker services from 7 days per week, 7 hours per day, 49 hours per week to 12 hours per day, 84 hours per week is modified. Medical Necessity is substantiated for 10hrs/day (70 hrs/week).