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

The patient is a 32-year-old female with a body mass index (BMI) of 40.4. The patient has undergone a psychological evaluation and is an appropriate candidate for weight loss surgery. She wishes to undergo gastric bypass surgery. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary for treatment of the patients morbid obesity.With a BMI of 40.4, gastric bypass surgery is medically indicated and necessary for this patient, as it is not likely that she will be able to lose weight and maintain the weight loss through non-surgical means. Furthermore, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomaticFindings:  Two physician reviewers found that there is sufficient support for the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Final Result: Two reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Gel One injection for the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested service is medically indicated. Therefore, a Gel One injection for the right knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male has requested applied behavioral analysis (ABA) therapy for treatment of his autism. Findings:  The physician reviewer found that the medical literature strongly supports the treatment of autism with ABA therapy.  ABA is an intensive behavioral intervention program that was first reported by Lovass in the 1970s.  ABA therapy has a documented 40 year history of substantially improving motor, verbal, and socially interactive skills in autistic children (Myers, et al.). ABA therapy has been proven effective in multiple controlled studies (Turner, et al.; Sallows and Graupner; and Remington, et al.). It is medically necessary and appropriate that the patient receive nine hours of ABA therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested for Avastin for treatment of her metastatic breast cancer.  Findings:  The physician reviewer found that Avastin does show activity in metastatic disease especially when combined with paclitaxel as reported by Miller and colleagues. These findings are also reported by Chan and colleagues and lend support for the treating oncologists proposed regimen. Abraxane is an alternate formulation of paclitaxel as noted by Ibrahim and colleagues.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fractured teeth
Treatment: Root canal (on front tooth) and white glass with high gold content crown, tooth #7 and #10)
The insurer denied the Root canal (on front tooth) and white glass with high gold content crown, tooth #7 and #10)
The denial is overturned, in part.

The patient is a male requesting a root canal procedure and crowns on teeth #7 and #10. The denial was due to lack of evidence for need according to plan documents.

Yes, in part; the proposed crowns on teeth #7 and #10 are medically necessary.  However, no in part; the root canal procedure is not medically necessary.

Although the photos presented are of poor quality, they do show the teeth in question have fractured. Their incisal edge portions to the extent that the dentin (tooth layer below the enamel) is most probably exposed. High quality photos from the providers office would help to show this. When these teeth are fractured into the dentin, then the sensitivity and pain the patient is experiencing makes sense. The need for crowns to restore the lost tooth structure is medically necessary.

However, before root canal procedures are needed, temporary crowns should be placed on these teeth to see if the symptoms subside. These teeth may not need the root canal procedures done to them.  If placing the temporary crown covers up the exposed dentinal tubules (i.e. the "pores" of the teeth) and the symptoms go away, then the root canal procedures are not needed.  If, however, the teeth remain sensitive after the temporary crowns are in place, then the root canal procedures are needed. The photos and x-rays presented do not show cracks in the teeth or any infections, so the symptoms the patient feels could be from the missing tooth structure on the tooth edges. Condemning the teeth for root canals before testing is incorrect treatment. The root canals are not medically necessary at this time.

Yes, in part; the health plan acted reasonably, with sound medical judgment and in the best interest of the patient for the root canals, however, not for the crowns.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Patent ductus arteriosus

Treatment: Inpatient hospital

The insurer denied coverage for inpatient hospital

The denial is modified

 
Pre-term male infant, birth weight 2020 grams. Pertinent to this denial is that the infant had been exhibiting slow oral (p.o.) feeding with occasional tachypnea and tachycardia. Cardiology identified a large patent ductus arteriosus (PDA) on an echocardiogram. As documented by the Attending Neonatologist, "PDA reported as being larger and increased size of left ventricle, baby reported as feeding slower and occasionally tachycardic. After talking to pediatric cardiology and because boy over 2 weeks old and PDA still large with increased left ventricle (LV), pharmacologic therapy is advised at that point".  Accordingly, treatment with Ibuprofen (to induce medical closure) was initiated. A previously heard murmur was not detectable. The infant's weight was 2385 grams, an increase of 35 grams from prior day. Feeds were increased to 45 milliliters (ml) (all P.O.).  The plan included a repeat echocardiogram. Hematocrit was 28% and iron was adjusted for weight. The infant weighed 2430 grams and was taking full p.o. feeds.  A repeat echocardiogram showed a small, restricted PDA. A circumcision was done, and the patient was discharged.

This was a growing preterm infant who had been symptomatic with a significant PDA and who was completing a course of Ibuprofen in the afternoon. Subsequently, the infant was asymptomatic, taking full feeds, and growing. A repeat echocardiogram that verified a response to Ibuprofen was not done until 3 days after completion of treatment. The reviewer did not find a progress note for the end of the stay.  It appears the infant remained hospitalized over the weekend awaiting an echocardiogram on a Monday that could have been done sooner. Also, it appears the circumcision could have been done sooner. 

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 an inpatient admission is modified. Continued stay for three days is substantiated. Two final days were not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Osteoporosis, hypertension and osteoarthritis.
Treatment:  Personal Care Aide (PCA) Level 2: 8 hours per day - 7 days per week - a total of 56 hours per week.

The insurer denied coverage for Personal Care Aide (PCA) Level 2: 8 hours per day - 7 days per week - a total of 56 hours per week.  The denial is modified.

This is an elderly female with chronic medical problems including osteoporosis, hypertension and osteoarthritis.  She lives with her spouse in a private residence.   However, her spouse is in a skilled nursing facility at this time.  The patient's son is reportedly supportive and involved in her care.  The insurer approved personal care aide (PCA) level 2: 4.5 hours/day, 5 days/week (22.5 hours/week), and the request is for 8 hours/day, 7 days/week (56 hours/week), which is under review.

The Uniform Assessment System (UAS) report was reviewed.  The patient's cognitive skills are described as modified independent.  She is reportedly totally dependent to maximal assistance for completing much of her instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  She reportedly requires extensive assistance for bathing and lower body dressing.  Limited assistance is reportedly needed for upper body dressing, bed mobility, locomotion, toilet transfer/use and ambulation.  She is independent with personal hygiene and eating.  She is occasionally incontinent of bladder and continent of bowel.  

The patient's self-sufficiency and activities of daily living (ADL) status have reportedly declined over the prior 90 days.   The patient's clinical condition and functional ability are not at a level or unpredictable as to require the requested PCA level 2: 8 hours per day, 7 days a week, for a total of 56 hours per week.   However, her declining functional ability supports PCA services 7 days/week.  As such; her clinical condition and functional ability support increasing PCA level 2: 4.5 hours per day, 7 days a week, for a total of 31.5 hours per week.   The patient may require additional monitoring; particularly due to her cognitive status and falls risk.  Safety monitoring under PCA 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, attention to the patient's physical needs can be appropriately provided and maintained by increasing PCA services to 4.5 hours/day, 7 days/week, totaling 31.5 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: 8 hours per day - 7 days per week - a total of 56 hours per week services is not substantiated. However, increasing PCA level 2: 4.5 hours per day, 7 days per week for a total of 31.5 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Ulcerative Colitis
Inpatient Hospital

The patient is a female with a medical history of ulcerative colitis on mesalamine and budesonide. She presented to the emergency department with abdominal pain for 4 days, watery diarrhea, nausea, and vomiting. Her vital signs were notable for fever with temperature of 103 Fahrenheit, tachycardia with pulse rate of 118/minute, and low blood pressure of 91/59 mm Hg. Her physical examination was notable for oropharyngeal exudate, abdominal distention, and generalized abdominal tenderness with rebound tenderness. 

A computed tomography (CT) scan of the abdomen and pelvis showed acute enterocolitis involving the colon and distal small bowel, most prominent in the distal rectosigmoid colon and distal small bowel; small partially loculated free fluid in the pelvis with prominent surrounding inflammatory changes near the sigmoid colon, prominent edematous/inflammatory changes in the mesentery, moderate dilation of the proximal small bowel without abrupt transition into non-distended thickened distal small bowel which could be due to ileus; distal small bowel obstruction cannot be completely excluded. She was made nil per os (nothing by mouth). She was treated with intravenous corticosteroids and Zosyn.

A Gastroenterology consultation concluded that she had a severe ulcerative colitis flare, with surgery as the most viable option; the recommendation was to keep nil per os, continue serial abdominal examinations, check C-reactive protein daily, start methylprednisolone, and check labs required before starting a tumor necrosis factor antagonist medication (hepatitis B serology and tuberculosis testing).

The health plan has denied the inpatient hospital stay as not medically necessary. The health plan's determination is overturned, in part. The first three days at issue were medically necessary. The last day was not. The patient had abdominal pain, nausea, diarrhea, and hematochezia consistent with ulcerative colitis. Imaging and flexible sigmoidoscopy showed severe disease, and the patient demonstrated signs of severe disease including fever, tachycardia, and severe leukocytosis on presentation. She had ongoing diarrhea and limited oral intake two days after presentation. On hospital day four, the flexible sigmoidoscopy had been completed and she was able to tolerate a diet that would sustain nutrition outside the hospital. Before that date, she was at risk for severe complications of ulcerative colitis including perforation, abscess, and toxic megacolon, and at risk for needing surgery; close monitoring was required. Therefore, the inpatient level of care is supported until and including that day. After that date, as she was clinically feeling well and tolerating oral intake with normal bowel movements, the inpatient level of care was not supported.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 

The insurer denied extraction of tooth # 1 and # 16, and general anesthesia each 15 minutes. 
The denial is partially overturned. 

The patient is a female who has been approved for removal of impacted tooth 32 and 30 minutes of general anesthesia. Extraction of tooth #1 and tooth #16 have been denied as there is no documentation of severe pain in these teeth, or that they will not erupt on their own. 30 minutes of additional anesthesia has been denied. The subject under review is the medical necessity for extraction of impacted tooth with bone, tooth 1, 16 and general anesthesia. 

The health plan's determination is overturned in part. 

The removal of tooth #1 and tooth 16 are medically necessary. The additional anesthesia is not medically necessary without an anesthesia record that documents the need for the additional time. 

The American Association of Oral and Maxillofacial Surgeons (AAOMS) Parameters of Care states that an impacted third molar that is so positioned that it will probably not erupt by the middle of the third decade constitutes pathology with dental and medical consequences. To limit known risks and complications associated with surgery, it is medically appropriate and surgically prudent to remove impacted third molars before the middle of the third decade and prior to complete root development. An impacted tooth with completed root formation that is totally covered by bone in a patient beyond the third decade that does not meet the following indications for removal should be monitored for change in position and/or development of pathology, which may then indicate its removal. The patient meets these criteria as the patient has impacted wisdom teeth that are so positioned that they will probably not erupt by the middle of the third decade. In addition, even if the teeth erupt, they will be unopposed and nonfunctional. 

Extraction of teeth # 1 and # 16 are medically necessary and is overturned. General anesthesia - each 15 minutes is not medically necessary and is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anemia
Treatment: Inpatient hospital admission
The insurer denied coverage for an inpatient hospital admission.
The denial is modified.

This patient presented to the emergency department (ED) with complaints of bilateral flank pain and bilateral lower extremity edema and was admitted with symptomatic anemia. Upon examination she had leg swelling with no deep vein thrombosis (DVT) on imaging. Lab values showed a Hemoglobin (Hgb) of 4.4 and a Hematocrit (hct) of 15.5. The patient was admitted and was given two units of packed red blood cells while in the ED. She was also administered Protonix and Tylenol. Imaging revealed a subchondral cyst like lucency of the left acetabular roof. The patient's vital signs were stable and her Hgb level showed improvement following treatment.

"Routine endoscopy in children and adults is usually performed in an outpatient setting using parenteral or general anesthesia." (Ahlawat R, Hoilat GJ, Ross AB, 2022)

"Anemia is a reduction in hemoglobin (Hb) or hematocrit (HCT) or RBC (red blood cell) count. It is a presentation of an underlying condition and can be subdivided into macrocytic, microcytic, or normocytic. Patients with anemia typically present with vague symptoms such as lethargy, weakness, and tiredness. Severe anemia may present with syncope, shortness of breath, and reduced exercise tolerance." (Turner J, Parsi M, Badireddy M, 2022)      

The patient presented with symptomatic anemia and was transfused with two units of RBC's in the emergency room (ER) for a low Hgb of 4.4. Once that was completed there was no longer any reason to keep her in the hospital. The medical records indicate the patient received another unit of RBC. The lytic acetabular lesion did not require a continued stay and could have been worked up as an outpatient. A deep vein thrombosis (DVT) was ruled out while in the ED. The patient underwent an endoscopy and colonoscopy in the hospital, which are outpatient procedures. The reviewer of systems (ROS) and physical examination (PE) were non-contributory. The patient could have been discharged to complete the work up as an outpatient.

The insurer's denial of coverage for the inpatient hospital admission is modified. Allow the admission from day 1 to day 2 but uphold denial of day 3 to day 4.  Medical necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vaginal Bleeding. 
Treatment: Inpatient Services. 
The insurer denied coverage for inpatient services. 
The denial is modified. 

The patient is a female at 35 weeks gestation who presented to the emergency department with complaints of painless vaginal bleeding. There was no evidence of blood clots. 

The patient was admitted for vaginal bleeding and concerns for pre-term labor. The treatment plan included fetal monitoring, intravenous fluids, intravenous antibiotics, magnesium and betamethasone. The patient's vital signs were stable, and she did not have any further episodes of bleeding. She was discharged with instructions to follow up with Obstetrics. 

According to MCG (Milliman Clinical Guidelines) admission is indicated for one or more of the following: Condition requiring premature delivery: Fetal distress or demise, preterm prelabor rupture of membranes, significant maternal disease, vaginal bleeding, complications of tocolytic treatment, continued fetal monitoring that require inpatient care, tocolytic therapy needed that requires inpatient care, and inability to stop preterm labor. 

This patient had vaginal bleeding with concern for placenta previa or abruption in a multigravida. Admission for monitoring and close follow-up was needed. However, there was no evidence of bleeding or cervical dilation and continuous admission was not medically necessary. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

Inpatient services on day 1 is considered medically necessary for this patient. However continuous admission on day 2 was not 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 inpatient services is modified. Medical Necessity is partially substantiated.