Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gender Dysphoria
Treatment: surgical services
The insurer denied Application of Skin Substitute with Use of Operating Microscope
The health plan's determination is upheld.

The patient is a transgender male who underwent left free radial forearm phalloplasty reconstruction. The radial forearm flap will be used for shaft only. The proposed health service in question is the application of skin substitute for the radial forearm donor site with the use of operating microscope.

The application of Skin Substitute with Use of Operating Microscope is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The radial forearm donor site is a common free flap donor site for a variety of reconstructions including phalloplasty. After the harvest of the radial forearm flap, the donor site is closed with a full thickness skin graft or a partial thickness skin graft. It is not the standard of care to apply Integra (skin substitute) for the closure of radial forearm donor site. Further, there is no reason for an operating microscope to be used for the placement of Integra. Operating microscopes are used for microsurgery such as connecting of blood vessels and nerves. They are not used for the application of skin grafts.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vomiting (gastroparesis). 
Treatment: Inpatient admission. 

The insurer denied: Inpatient admission. 
The denial is partially overturned. 

The patient is an adult female with gastroparesis. She presented an eight-day history of intractable nausea / vomiting and diarrhea. The patient was seen at an outside hospital three times before admission. Her husband had a viral gastroenteritis.
The patient was treated with IVF (intravenous fluids), antiemetics, and IV (intravenous) morphine for abdominal pain, but this was discontinued as she was also having constipation issues. GI (gastroenterology) was consulted and agreed with conservative management. 
The next day, the patient was sipping some clear liquids. She did not have any significant pain. She vomited the previous day. 
The following day, the patient was on clear liquids and the diet was advanced slowly to low fat as tolerated. She tolerated crackers and toast in the morning. 
On day three, the patient was restarted on IV (intravenous) morphine, Compazine IV (intravenous), Ativan IV (intravenous) with a very good response. 
On day four of the admission, the patient was able to tolerate her diet and requested to be discharged home. 

The inpatient admission was medically necessary, in part. 
An inpatient admission was medically necessary for the day of admission and the next day, with discharge on the day after. The inpatient admission was not medically necessary from that day and forward. 

The initial inpatient admission was medically necessary for slow advancement of diet, administration of IV (intravenous) fluids, and control of pain. The second day of admission, the patient was on clear liquids and the diet was advanced slowly to low fat as tolerated. She tolerated crackers and toast in the morning. 

The patient could have discharged at that time as the patient was tolerating a diet. The medical records do not support that the acute inpatient admission was medically necessary from that day and beyond. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting. 

The patient did not require any procedural or surgical intervention, did not require to be nothing by mouth, did not have acute kidney injury, did not have electrolyte derangement needing intravenous replacement, did not have fevers, did not have an elevated white count, and did not have any complications such as intra-abdominal abscess or a surgical abdomen.
Appeal type: Medical necessity
Decision: Overturned

Back Pain
Radiology Services (including Ultrasound)

The patient is a male who presents with bilateral lower extremity pain. The patient was evaluated by his vascular surgeon for leg pain and based on the documentation, the specialist believes the pain may be from a primary neurologic source. The provider is recommending an magnetic resonance imaging (MRI) of the cervical, thoracic and lumbar spine to rule out a neurologic source of leg pain.

The health plan's determination is overturned in part. The MRI of the cervical and thoracic spine are not medically necessary and are not standard of care diagnostic tests used to assess leg pain.
The MRI of the lumbar spine is medically necessary to evaluate the patient's leg pain and to rule out abnormal conditions of the lumbar spine potentially causing pain to the lower extremities.
The patient was evaluated by his vascular surgeon for leg pain and based on the documentation, the specialist believes the pain may be from a primary neurologic source. The MRI of the lumbar spine is an appropriate diagnostic test to evaluate spinal stenosis, a condition that often mimics vascular disease in the lower legs. In this case, the patient presents with lower extremity pain and thus an MRI of the lumbar spine is medically necessary based on the peer reviewed literature and the current standard of care in the United States.
The MRI of the cervical and thoracic spine are not useful in the evaluation of lower extremity pain or neuropathy and are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory system /Breathing problems 
Treatment: Inpatient hospital 
The insurer denied the entire  inpatient stay
The denial is overturned in part 

The patient with hypertension (HTN), emphysema, nut allergy, and gastroesophageal reflux disease (GERD). The patient presented to the emergency department (ED) with tongue swelling and dyspnea 2 hours after eating almonds.

Yes, the inpatient admission was medically necessary in part for the first 2 days. The admission was not medically necessary on the last 2 days.  He required an inpatient admission on the first two days  because of his increased risk of respiratory failure and late response. The patient did not require inpatient admission after the last 2 days  because his condition had improved, and his risk of recurrence was low.

The inpatient admission was reasonable for the first 2 days . He had anaphylaxis with upper airway symptoms and required more than one round of intramuscular (IM) epinephrine. This does suggest a higher risk of respiratory failure and a bi-phasic/late recurrence. These patients do need close monitoring to monitor airway status as they can decompensate quickly and require advanced airway management.

However, by the 3rd day, the patient had improved and there was no longer a need for ongoing observation. He was improved and feeling better, the endocrine physician's recommendations were to continue low dose sliding scale while an inpatient, start an oral agent on discharge, and follow-up with endocrinology. These are all things that can be done at a lower level of care as they do not require close inpatient monitoring or inpatient only testing or treatment. This largely represents a chronic problem. Typical recommendation for a lower level of care, as in literature cited below, is 24-48 hours. The patient had improved within 24-48 hours, and therefore an ongoing admission was not needed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Social Anxiety Disorder F40.10
Treatment: Consumer Directed Personal Assistance Service for 56 Hours Per Week
The insurer denied: Consumer Directed Personal Assistance Service for 56 Hours Per Week
The denial is partially overturned.

This case involves an adult male diagnosed with social anxiety disorder associated with substantial impairments in functioning including basic and instrumental activities of daily living. The patient is requiring five to six hours of personal care assistance for meal preparation, shopping, medication administration, and his CPAP (continuous positive airway pressure) device. Additionally, the patient requires accompaniment to appointments and assistance with instrumental activities in order to maintain his home environment. Additionally, the patient's mother, with whom he lived, passed away last year which has compounded the patient's living situation. The patient's brother has stepped in to assist the patient accordingly. The requested personal care assistance services with up to 56 hours per week has been denied coverage based on medical necessity. The denial determination indicates that current allotment of five hours is sufficient for the patient's needs.

The appeal is based on the patient's functional impairments indicating that the patient needs five to six hours per day or 35 hours per week of personal assistance, and the initial request for 56 hours per week is not needed. 

The proposed treatment of the requested health service/treatment of Personal Care Assistance Services with up to 35 hours per week is medically necessary for this patient. 

The submitted documentation together with the case summary and other materials including the caregiver statement, clearly indicate the need for the personal care assistance, as requested. The patient's psychiatric condition together with functional impairments do require the level of assistance that has been requested in this case scenario. There is documented evidence that the patient's functioning and the psychiatric conditions have improved but may have worsened with the death of his mother. Thus, the requested benefit of Personal Care Assistance Services is medically necessary for this patient with up to five to six hours per day and 35 hours per week.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned in part.

This is a male patient who presented to the emergency department (ED) with complaints of abdominal pain for 1 day. He had a known history of gallstones. The comorbid health conditions included osteoarthritis.  An ultrasound showed gallstones and gallbladder wall thickening. A hepatobiliary iminodiacetic acid (HIDA) scan showed a cystic duct obstruction suggestive of acute cholecystitis.
He was admitted to the hospital and initially treated with intravenous (IV) fluid, antibiotics, and antiemetics. The initial surgical plan was for a cholecystectomy. However, the patient declined operative treatment and wanted only antibiotic therapy. The patient reported feeling better. He had normal vital signs. He still had right upper abdominal tenderness on exam.
He was started on a liquid diet. The vital signs were normal. The WBC count normalized. The abdomen was non-tender and he required no pain medications. He was discharged.

An inpatient level of care was medically necessary in this case, in part, for the first 3 days. This patient presented the ED and was diagnosed with acute cholecystitis. The WBC count was elevated at 17.9 thousand (K). An ultrasound showed gallstones and gallbladder wall thickening. A HIDA scan showed cystic duct obstruction consistent with acute cholecystitis. A surgical consultation was performed. A non-surgical treatment plan was provided with intravenous (IV) antibiotics. The WBC count normalized and the patient was tolerating a diet. He was stable for discharge from the inpatient setting with continued outpatient follow up.

The patient had acute cholecystitis with right upper quadrant pain and tenderness. He had systemic signs of inflammation as supported by a WBC count greater than (>) 10, and cholecystectomy was not anticipated as interval cholecystectomy was planned per the surgical progress notes to be performed in the outpatient setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: full hospital admission

The insurer denied coverage for full hospital admission

The denial is modified

This adult male reportedly was admitted to this inpatient hospital after he had an overdose after snorting cocaine which was suspected of being laced with opiates. He reportedly had altered mental status and syncope in the setting of a drug overdose and was hypoxic with bradypnea and had hyperkalemia, lactic acidosis, and had glucose in the 700's, and had elevated liver function test (LFT's). He reportedly also had an abnormal (electrocardiogram) EKG and was given aggressive intravenous (IV) fluids, IV antibiotics, and IV heparin. He reportedly was given Narcan and responded with improved mental status. He was discharged.
     
This reviewer disagrees with the decision to deny coverage for acute inpatient hospital treatment on day 1 as the medical records provided enough specific evidence to support that he required hospital treatment then but agree with the decision to deny coverage for the remaining 2 days as the medical records did not provide enough specific evidence to support that he still required 24-hour acute hospital treatment. 

According to the Milliman Care Guidelines (MCG) Guidelines for Drug verdose/Ingestion, he met criteria for hospitalization on day 1 as he had altered mental status initially and had other medical issues including being hypoxic with bradypnea and had hyperkalemia, lactic acidosis, and had glucose in the 700's, and had elevated LFT's. He reportedly required and received aggressive IV hydration due to his lactic acidosis, in addition to the aggressive IV hydration with IV fluids. 

The medical records supported that he was considered a medical risk and at risk for withdrawal as he reportedly used cocaine which was thought to possibly being laced with opiates and he reportedly had syncope and altered mental status after that with medical consequences including being hypoxic with bradypnea and had hyperkalemia, lactic acidosis, and had glucose in the 700's, and had elevated LFT's. He required the day in the hospital for treatment and monitoring. However, notes on day 2 reported that he had improvement in mental status and was stable and asymptomatic with no signs of infection and he had stable vital signs. He reportedly was alert and oriented and after aggressive IV hydration and it was reported that that treatment improved his lactic acidosis. It also was reported that Narcan improved his mental status. He reportedly still was improved on day 3 and was discharged. As a result, the recommendation is to modify the previous decision and approve coverage for hospital treatment for 1 day but deny coverage for remaining 2 days.

It appeared that the insurer acted reasonably for remaining 2 days but did not act in the best interest of the patient for 1 day.

Based on the above, the insurer's denial must be modified. The health care plan act partially reasonably with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient level of care is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Personal Care Aide (PCA) Level 2: 7 hours per day - 7 days per week - for a total of 49 hours per week
The insurer denied: Personal Care Aide (PCA) Level 2: 7 hours per day - 7 days per week - for a total of 49 hours per week
The denial is: Overturned in part

The patient is a female with medical history notable for osteoarthritis, inflammatory arthritis, and heart disease. The patient is approved for 5 hours per day, 4 days per week and 4 hours per day, 2 days per week (total of 28 hours per week) of level 2 personal care services. The patient requested an increase to 7 hours per day, 7 days per week (49 hours per week). This request was denied by the insurance company, and this denial is the subject under review.

The health plan's determination is overturned in part. 

The requested Personal Care Aide (PCA) Level 2: 7 hours per day - 7 days per week - for a total of 49 hours per week is not medically necessary for this patient.
The patient has severe limitations in mobility due to arthritis that impact her ability to perform Instrumental activities of daily living (IADLs) and activities of daily living (ADL's). This is clearly documented in the UAS assessment. She demonstrated worsening in functional status in the most recent functional assessment and should have a commensurate increase in personal care hours. The task tool recommends 33 hours per week as a minimum to address her personal care needs. It would seem appropriate to provide her with this level at a minimum. Given her needs, she should receive personal care 7 days per week.
Personal Care Aide at 5 hours per day, 7 days per week is medically necessary for this patient. This would meet the minimum set forth by the task tool and should account for her personal care needs as described by both the patient and the Uniform Assessment System (UAS).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anemia.
Treatment: Inpatient admission.

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

The patient was referred to the emergency room by her nephrologist for rectal bleeding for 4 weeks with melanotic stools and associated anemia. She had a past medical history significant for iron deficiency anemia, chronic kidney disease, diverticulosis, hypertension, and diabetes mellitus. Upon presentation to the emergency department, the patient was described as short of breath on exertion, she was lightheaded, fatigued, having chills, positive guaiac, with relatively stable vital signs, but she had pale skin and black stool. Significant labs included white blood count (WBC) 11.5, Neutrophils 77.4, Absolute Neutrophil Count (ANC) 8.9, hemoglobin (Hgb) 6.0, hematocrit (Hct) 20.9, glucose 157, blood urea nitrogen (BUN) 65, Creatinine 4.40, potassium (K+) 5.3, Chloride (Cl) 113, carbon dioxide (CO2) 17.2 and estimated glomerulofiltration rate (EGFR) 10. She was subsequently admitted for a transfusion of packed red blood cells with continued monitoring with complete blood count. She underwent a gastrointestinal bleed work-up and management of acute kidney injury. The patient's prior nephrology evaluation noted an acute kidney injury with prerenal azotemia due to severe anemia and gastrointestinal bleeding. She had chronic kidney disease stage (IV) with secondary hyperparathyroidism, hyperuricemia, diabetic neuropathy, type 2 diabetes mellitus, hypertension, hyperlipidemia, and obesity.

The healthcare plan acted reasonably and with some medical judgment and in the best interest of the patient but should have taken into consideration that there were life-threatening issues that needed to be addressed at an inpatient level of care until the patient stabilized.

According to the Milliman Care Guidelines, a clinical indication for admission to inpatient care for a patient with lower gastrointestinal bleeding includes anemia with exertional dyspnea, which was noted at the time of presentation to the emergency department. Given the patient's comorbidities, inpatient care for the first four days was reasonable given that it was determined that the patient was critically ill with a high probability of imminent or life-threatening deterioration.  The patient had stabilized with a hemoglobin level at 8.7 posttransfusion. Therefore, the prior determination is partially overturned.

The insurer's denial of coverage for a full hospital admission is modified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Non-viable pregnancy 
Treatment: Acute inpatient stay 

The insurer denied coverage for acute inpatient stay. The denial is modified. 

This patient is a female G11 P5 who presented to the Emergency Department (ED) at 15.5 weeks gestation. The patient's cervix was 2 cm dilated and 100% effaced. The patient was admitted for vaginal progesterone. The poor prognosis was discussed with the patient. The patient was offered conservative management versus termination. Based on the review of the medical chart, progress note documented that the patient was receiving vaginal progesterone. The patient delivered a non-viable fetus without complications, and was discharged home. 

The patient had a short cervix.  The patient was admitted and placed on Lovenox prophylaxis and vaginal progesterone. From the information submitted, it appears that a cerclage placement was not feasible. 

The value of prolonged hospitalization for women with short cervix has been studied and the scientific literature showed that admission to the hospital was not associated with a decreased rate of preterm delivery and there was a trend toward hospitalization as an independent risk factor for delivery at < 34 weeks, an earlier gestational age at delivery, and a shorter time from diagnosis to delivery. Hospitalization was independently associated with an increased rate of cervical shortening. Another study showed that activity restriction did not reduce the rate of preterm birth in asymptomatic nulliparous women with a short cervix. However, women with vaginal bleeding, no reassuring fetal status, or a long travel time to a hospital with appropriate levels of obstetric and neonatal care services are examples of obstetrically unstable patients in whom ongoing in-hospital observation may be useful. 

In this case, this patient did not have any of the above circumstances. This patient had a non-viable pregnancy. The patient could have been sent home on bed rest with temperature monitoring. If fever developed or if the patient's amniotic membranes ruptured or cramping developed, then the patient could have returned to the hospital. In this case, the patient was afebrile and was stable at admission and during the inpatient stay. Thus, inpatient admission was not medically necessary. However once the patient went into labor, admission was medically necessary for delivery and postpartum management as per standard of care. Thus, the acute inpatient stay is not considered medically necessary for this patient. However admission was medically necessary. 

The health care plan acted reasonably with sound medical judgment to deny coverage for the inpatient stay for specified dates, but not in the best interest of the patient to deny coverage for inpatient stay for other specified dates thereafter. 

Based on the above, the medical necessity for the acute inpatient stay is partially substantiated. The insurer's denial should be modified. DENY specified dates. APPROVE specified dates thereafter.