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

Diagnosis: Hypertension, diabetes and dementia

Treatment: personal care aide (PCA) 24 hours, 7 days x 12 hours x 2 shifts, for a total of 168 hours per week

The insurer denied coverage for personal care aide (PCA) 24 hours, 7 days x 12 hours x 2 shifts, for a total of 168 hours per week

The denial is modified

This is an elderly female with hypertension, diabetes and dementia.  She lives alone in a private residence.  The insurer approved personal care aide (PCA) 63 hours/week and the request is for PCA 24 hours, 7 days x 12 hours x 2 shifts for a total of 168 hours per week; leading to an external review.  

The Uniform Assessment System (UAS) was reviewed.  The patient's cognition is described as severely impaired.  She is reportedly total dependent for completing much of her Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires maximal assistance for bathing, personal hygiene, and toilet use.  Extensive assistance is reportedly needed for dressing, toilet transfer, locomotion and ambulation (uses a walker).  Limited assistance is reported needed with eating and bed mobility is independent.  The patient is reportedly incontinent of bladder and bowel.  There has been no reported functional change or falls over the prior 90 days.  The patient's cognitive and functional ability are much the same when compared to the prior UAS report.   

The hospital note describing the patient's hospital course was reviewed.   She was treated with antibiotics for a urinary tract infection and "Her mental status retuned to baseline."  The hospital note does not describe a level of care, medical condition or level of functional incapacity that requires the requested PCA 24 hours, 7 days x 12 hours x 2 shifts for a total of 168 hours per week.  However, her functional limitations do support increasing the current PCA services.  While this physician would also agree that the patient may benefit from additional monitoring; particularly due to her reported cognitive decline, weakness and falls risk, safety monitoring under PCA services does not include monitoring an individual (e.g., with dementia, falls risk, general weakness) 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 at home by increasing PCA services 12 hours/day, 7 days/week for a total of 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) 24 hours, 7 days x 12 hours x 2 shifts, for a total of 168 hours per week services is not substantiated. However, PCA 12 hours/day, 7 days/week for a total of 84 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma Exacerbation and Breakthrough Seizure.

Treatment: inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is modified.

The patient has a history of chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA) on continuous positive airway pressure (CPAP), diabetes mellitus (DM), hypertension (HTN), Seizure Disorder who presented to the emergency department (ED) with complaint of shortness of breath (SOB) and some chest tightness. The patient was noted to be wheezing so was administered breathing treatments on the way to the hospital.  Labs revealed white blood count (WBC) was 9.8. The patient was hypomagnesemic to less than 1. Electrocardiogram (EKG) revealed prolonged QTc (interval on EKG). The patient had a seizure while in the ED. No tongue bite or injury. No loss of consciousness (LOC). The patient had a head computed tomography (CT) which was unremarkable. Neurology was consulted. The patient was loaded with Keppra and started back on oral Keppra bid [twice daily].

The patient was admitted to the hospital for asthma exacerbation and breakthrough seizure.

Chest x-ray did not reveal any pneumonia. The patient was given IV (intravenous) magnesium. Treatment for asthma continued with steroids, bronchodilators (BD) and PO [oral] antibiotics. Pulmonary recommended to taper steroids.

Vital signs in the emergency department were temperature 98.2, heart rate 108, respiratory rate 28, blood pressure BP (blood pressure) 128/86 and oxygen saturation 95% (percent). The patient was using accessory muscles. The lung exam revealed bilateral wheezes. Peak expiratory flow (PEF) was 150. The patient was started on intravenous (IV) steroids, bronchodilator.

Given the patient multiple comorbid diagnoses admission for evaluation and treatment was medically necessary. However, two days later from admission date, the patient was feeling much improved, was afebrile and hemodynamically stable with no further seizures. The patient was alert and oriented with non-focal neurological exam. Peak Expiratory Flow (PEF) up to 300. Lungs were clear. Arterial blood gases were unremarkable and there was no CO2 (carbon dioxide) retention.  The patient was on oral seizure meds. She has been evaluated by Pulmonary and Neurology; at that point she did not need further inpatient stay.

The health plan acted reasonably in part with regard to the length of stay but not the admission. 

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

Diagnosis: left basal ganglia hemorrhage

Treatment: Subacute Rehabilitation

The insurer denied coverage for Subacute Rehabilitation.

The denial is modified.

 
This is an adult male with diagnosed left basal ganglia hemorrhage. He lives alone in a 6th floor walk-up apartment. Under review is the medical necessity of continued subacute rehabilitation stay at a Non-Skilled level of care.

The patient's clinical condition and functional ability were not at a level to support subacute rehabilitation stay at a Non-Skilled level of care for part of the time frame under review. However, the clinical records demonstrate a level of continued improvement that supported his continued stay for rehabilitation at a Non-Skilled level of care for a few more weeks. According to the case notes, the patient was independent with dressing/footwear and supervision for toilet transfer/toileting. He was only ambulating approximately 25 feet with a walker and supervision. He continued to improve and the patient was able to ambulation 175 feet with a rolling walker, and at the "set-up" level for toileting, bathing and dressing and bathing. Given the patient's living situation (lives alone in 6 floor walk-up), minimal community support and continued improvement; subacute rehabilitation stay at a Non-Skilled level of care for additional days was clinically appropriate. However, he could have been safely discharged home with home care services a few days 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 Subacute Rehabilitation stay at a Non-Skilled level of care the entire length of stay is not substantiated. However, subacute rehabilitation stay at a Non-Skilled level of care for a few more weeks was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Abdominal/Stomach Pain
Inpatient Hospital

The patient is a male with history of thoracic aortic aneurysm status/post (s/p) repair, metallic aortic valve placement on home anticoagulation, and current marijuana abuse who presented to the emergency department (ED) with episodes of bright red blood per rectum associated with abdominal pain. Hemodynamics were stable. The international normalized ratio (INR) was 2.1 while on coumadin. He was admitted to inpatient level of care for ongoing work up and management of his presenting complaint with hemodynamically stable lower gastrointestinal (GI) bleed. 

The health plan's determination is overturned in part. The inpatient health services are medically necessary with the patient's baseline comorbidities including psychiatric illness, aortic valve replacement and need for anticoagulation and presenting complaint of lower GI bleed with broad differential diagnosis. Initially infectious colitis was suspected based on the CT abdomen requiring IV antibiotics and then ischemic colitis was seen based on the colonoscopy. This required careful serial abdominal exams, reinitiating of diet and anticoagulation with Lovenox bridging with monitoring for further bleeding and serial complete blood count (CBC).
However, the patient could have been discharged on the 4th day after all the necessary procedures, and consults were done. The patient was stable hemodynamically with no further bleeding in the prior three days.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back and leg pain.
Treatment: CPT codes 22857 & 22585 - Removal of Gel Pad Between Back Bones
and New Gel Pad as Replacement, and/or Fusion, Pre-service.

The insurer denied the CPT codes 22857 & 22585 - Removal of Gel Pad Between Back Bones and New Gel Pad as Replacement, and/or Fusion, Pre-service.  The denial is partially overturned. 

The patient is a female with low back and leg pain. The patient failed PT (physical
therapy), pain management and had a previous microdiscectomy at L5-S1 (fifth lumbar spine vertebra - first sacral vertebra). MRI (magnetic resonance image) shows degenerative disc disease at L5-S1 (fifth lumbar spine vertebra - first sacral vertebra) with recurrent disc herniation causing left moderate to severe stenosis. X-ray shows no dynamic instability at L5-S1 (fifth lumbar spine vertebra - first sacral vertebra). The patient was recommended L5-S1 (fifth lumbar spine vertebra - first sacral vertebra) arthroplasty.

No, the proposed lumbar disc arthroplasty is not medically necessary.
The patient has a recurrent disc herniation at L5-S1 (fifth lumbar spine vertebra - first sacral  vertebra) but a lumbar arthroplasty is not considered medically necessary in this patient and would not be standard of care. The patient has evidence of recurrent disc herniation and has failed nonsurgical management but there is no supporting documentation for arthroplasty. Standard of care would indicate fusion. Arthroplasty in this setting would be considered outside standard of care and therefore is not medically necessary or appropriate in this setting.

REASON FOR ADDENDUM:
Please address the medical necessity of fusion for this patient specifically.

REVIEWER'S RESPONSE:
As mentioned, the patient has evidence of recurrent disc herniations, which is a sign of
microinstability causing disc herniations to recur. The use of fusion in this setting has been well demonstrated and supported by the literature. Patients who fail one to two microdiscectomies are indicated for fusion, as they have microinstability that is causing the disc to continue to recur. In this setting, such as the patient in this clinical scenario, fusion is appropriate and medically necessary as a means of treating the instability.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trauma. 

Treatment: Inpatient facility stay.

The insurer denied coverage for the inpatient facility stay. 

The denial is modified. 

This is a female patient who presented to the Emergency Department (ED) via the Emergency Medical Services (EMS) due to a gunshot wound.  The documentation indicated that the patient was shot while sitting in a car.  Initially, the patient was noted to be alert and oriented.  The patient was able to talk upon arrival to the ED.  The patient had a patent airway.  On day 2 of admission, the patient denied numbness and tingling as well as any voice changes.  The patient did not have any acute bleeding and there was minimal swelling.  The patient continued with treatment which included dressing changes as well as a swallow evaluation.  The patient also underwent additional imaging and continued treatment with analgesics.  The patient continued to improve and was discharged on day 3 of admission.

Regarding the requested inpatient stay, the referenced literature indicates that this patient may be admitted when there is evidence of significant trauma and a lower level of care cannot be provided safely.  This may include the need for frequent monitoring and/or when there is evidence of acute blood loss that may cause abnormalities.  The submitted documentation indicated that this patient presented with a gunshot wound to the cervical spine that resulted in bleeding that was not being controlled upon arrival to the hospital.  While it is noted that the patient had a patent airway, there is a lack of notes detailing the entirety of this stay was appropriate.  This patient would be appropriate for a 1-day inpatient admission to continue monitoring closely given the area of involvement and the possibility of swelling and airway compromise.  This patient did undergo a swallow evaluation and imaging.  There were no abnormalities documented that would warrant continued admission; thus, the request is partially overturned to allow an inpatient admission from day 1 of admission to day 2 of admission.

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

Inpatient admission from day 1 of admission to day 2 of admission was medically necessary. Inpatient admission for day 3 of admission is upheld. 

The insurer's denial of coverage for the inpatient facility stay should be modified. The medical necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Prolonged pre-C-section monitoring.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is modified.

The patient was admitted at 27 weeks and 3 days of gestation for prolonged monitoring before her cesarian (C) section. She has a history of a fetal anomaly of sacrococcygeal teratoma (SCT). 

She underwent a C-section delivery.  Her postpartum course was uneventful, and she was discharged home.

Sacrococcygeal tumors range in size and severity. Most of them feed on blood. This makes the tumor grow fast and the heart to work harder. It also may increase amniotic fluid, causing it to build up in other areas of the body. When this occurs, the fetus can develop hydrops. This is a condition that can lead to heart failure and endanger the lives of both the mother and baby. 

Prenatal diagnosis and close monitoring have improved outcomes for fetal sacrococcygeal teratoma (SCT), but overall perinatal mortality remains high. Estimates of perinatal mortality for prenatally diagnosed SCT range from 25 to 50 percent when cases of pregnancy termination, intrauterine death, and neonatal death are included. Potential perinatal complications include preterm labor, spontaneous tumor hemorrhage or rupture, and maternal Mirror syndrome (maternal edema and hypertension mirroring fetal hydrops).

In selected high-risk sacrococcygeal teratoma (SCT) fetuses, early delivery and ex utero surgery are an option. They suggest Cesarean delivery, using an ex utero intrapartum therapy (EXIT) procedure when possible, for high-risk sacrococcygeal teratoma (SCT) after 27 to 28 weeks is recommended. 

It is obvious from the above that this is a very specific case, and admission with very close monitoring with immediate intervention was medically necessary and standard of care.

Admission on was medically necessary. However, after the c-section, the patient was stable and could have been discharged on day 5. There was no medical reason for continuous admission, and the continuous admission day 6 and day 7 was not 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 the inpatient stay from day 1 to day 5 is substantiated. However, continuous admission for day 6 and day 7 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nausea/vomiting
Treatment: Inpatient stay 
The insurer denied the inpatient stay. The health plan's determination is overturned in part (3 day stay was medically necessary).

The patient is a woman with a history of alcoholic cirrhosis who presented with 2 days of nausea and vomiting. She had a history of recent liver transplantation. The patient was evaluated by the transplant team and was admitted to the hospital. The admitting condition was transplant rejection versus (vs) medication induced nausea and vomiting. The patient was noted to have worsening abdominal distention due to ascites. She had had prior paracentesis with evacuation of 8.6 liters of fluid. Abdominal ultrasound showed a normally perfused transplanted liver and ascites.

An inpatient level of care was medically necessary for 3 days. Continued inpatient care was not medically necessary after 3 days. This patient required an acute assessment of her liver transplant, assessment of ongoing immunosuppression and management of hypertension. The complexity of her condition in the setting of recent liver transplant and the reasonable expectation that her care would span a period of at least 48-hours supported the medical necessity of inpatient admission. She required the coordinated care of multiple medical/surgical services and adjustment of her ongoing immunosuppressive drug regimen.

However, as of day 3 the patient was tolerating a diet, there was no description of significant ongoing nausea or vomiting, liver function was normal based on lab data and the management of her headache could have reasonably been performed with a lower level of care in the outpatient setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral missing lower molars with supra-eruption of teeth #s 2-4. 
Treatment: Outpatient surgery (21206 x 2).
The insurer denied coverage for outpatient surgery (21206 x 2).
The denial is modified to allow right side segmental osteotomy.  

This patient is missing lower molars bilaterally. The patient is under the care of a dentist and oral and maxillofacial surgery (OMS). The patient has over erupted teeth 2-4. These three teeth are a fixed bridge. The entire bridge has over erupted. The treatment plan includes a segmental osteotomy to impact this segment allowing space for reconstruction of the lower arch with a partial denture. This request for outpatient surgery (21206 x 2) has been denied. 

To properly treat this patient space needs to be available for the reconstruction of the lower arch with a partial denture. in this case the fixed bridge touches the lower ridge. The best option includes the maintenance of these teeth and their impaction superiorly to gain space interocclusally. 

The outpatient surgery (21206 x 2) is not considered medically necessary; however, the outpatient surgery (21206 x 1) is considered medically necessary for this patient. 

The right posterior segment is the only segment that needs to be impacted. This is done from a functional standpoint to improve function by allowing room to place a lower partial. Therefore, the request for outpatient surgery (21206 x 1) is considered medically necessary for this patient. 

Shand, J.M., and Heggie A.A. (2016), "Among the well-established indications for undertaking segmental maxillary surgery are the management of an anterior arch length discrepancy and a narrow maxilla with posterior transverse discrepancy that can be resolved with surgical expansion. As the experience with orthognathic surgery techniques increased, together with the development of orthodontic expertise, segmental procedures were undertaken for specific occlusal or skeletal problems as part of a combined surgical/orthodontic treatment plan. In 1962, Wunderer described a modification of the Wassmund technique with the majority of the procedure being performed via a palatal approach. This helped to improve overall access whilst maintaining a broad buccal pedicle for perfusion. The Wassmund technique maintains more of the buccal and palatal mucosal pedicles, however the access provided results in a technically challenging procedure."        

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 outpatient surgery (21206 x1) services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dizziness; Chest pain
 
Treatment: Inpatient admission 

The insurer denied coverage for inpatient admission. The denial modified.

This patient is a female with a history of Type II Diabetes, Asthma, Hypertension, Hyperlipidemia, and gastroesophageal reflux, tobacco and alcohol dependence,  that was transported to the Emergency Room by Emergency Medical Services (EMS) for complaints of dizziness, midsternal chest pain, dyspnea, diaphoresis, nausea and vomiting.  On admission to the Emergency Room, the patient had a blood pressure of 169/93, a normal heart rate.  A battery of testing was completed.  There was a normal EKG, normal chest x-ray, CT of the head was normal, blood testing revealed low magnesium and potassium, troponin was normal with normal brain natriuretic peptide (BNP).  The patient was admitted for cardiac and neurological consultation.  An echocardiogram revealed a grade 1 diastolic dysfunction, a carotid ultrasound revealed right carotid stenosis, bilateral lower extremities Doppler ultrasound was negative.  The remainder of the cardiac enzymes were negative.  The patient was treated for the electrolyte imbalance, treated for her hypertension, and was discharged with follow up visits to the primary care physician, podiatry and ophthalmologist.

According to the MCG 23rd Edition guidelines for chest pain and dizziness, an inpatient hospitalization could have been considered for an extended period of observation of approximately 1 day (24 hours) however, there is no evidence that a 3 day inpatient hospital stay was indicated as the vast majority of the testing could have been done as an outpatient. Therefore, because a 24 hour observation would have been sufficient, the denial for coverage is partially medically necessary.  

The carrier's denial of coverage for the inpatient admission is modified.  Approve a specified date range.  Deny another date range.