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

Diagnosis: Broken amalgam filling, cavities
Treatment: Tooth Colored Crown for Teeth #s 3, 5, 7, 8, 9, and 10
Post and Hard Material Under Cap for Tooth #3
The insurer denied the Tooth Colored Crown for Teeth #s 3, 5, 7, 8, 9, and 10
Post and Hard Material Under Cap for Tooth #3
The denial is overturned, in part.

The patient is a female requesting crowns on teeth #'s 3, 5, 7, 8, 9 and 10. A cast post and core is also requested for tooth #3. 

The prior denial was due to the teeth not meeting requirements for treatments.

Yes, in part; the proposed treatment for teeth #'s 5 and 7 is medically necessary. However, no in part; the proposed treatment for teeth #'s 3, 8, 9 and 10, the proposed treatment is not medically necessary.
Tooth #5 has had a root canal procedure done to it and has a broken amalgam filling. There is not much solid tooth structure left. This tooth can only be properly restored with a crown.

Tooth #7 has two large cavities in it. Upon removal of all the decay, there will not be much solid tooth structure left. A crown is the only way to properly restore the tooth.

With the x-rays provided, teeth #'s 3, 8, 9 and 10 do not show any need for restorations. No decay is seen in the provided x-rays.  Therefore, no crowns (or cast post and core for #3) are needed.

Yes, in part; the health plan did act reasonably, with sound medical judgment and in the best interest of the patient for teeth #'s 3, 8, 9 and 10 as the proposed treatment was not medically necessary.  However, no, in part; the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient for teeth #'s 5 and 7 as the proposed treatment was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: upper gastrointestinal (GI) bleed

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission

The denial is modified. 

This male patient has a history of hypertension, dyslipidemia, and participation in a methadone maintenance program (MMTP).

The inpatient hospital admission is partially medically necessary. Full length of stay was not. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. However, an admission for two days should have been sufficient. The patient could have been transfused on the same day as admission and have recovered earlier with outpatient PPI.      

This patient presented to the emergency room (ER) , with hemoglobin (Hgb) level dropped from 10.1 to 6.3, over a month. He reports taking 10-12 aspirins per day, over the past month. The patient was admitted with severe anemia, likely secondary to an upper gastrointestinal (GI) bleed. On admission, Hgb was 6.6 (normal 13.5-17.5), and hematocrit (Hct) was 21 (normal 38.3-48.6). Stool occult blood was positive. The patient was started on a proton pump inhibitor (PPI). One unit of packed red blood cells (PRBC) was transfused . The patient was discharged.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. An admission for two days should have been sufficient.

The carrier's denial of coverage for inpatient hospital admission is modified.  The medical necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Uterine fibroids 
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned in part.

The patient is a female with a history of symptomatic uterine fibroids. The patient underwent an open abdominal myomectomy with removal of multiple fibroids and an ovarian cystectomy. Blood loss was 100 cubic centimeters (cc).

Post-operatively, she was stable. The foley catheter was removed on post-operative day 2. The progress note states the patient is doing well. The progress note on post-operative day 3 states the patient is doing well enough to discharge home. This patient underwent a laparotomy. Laparoscopies are ambulatory procedures, laparotomies are not. The standard of care is for patients who undergo an open procedure to stay in the hospital for 48 hours. 

On postoperative day 1, the Foley catheter is removed, the patient is encouraged to get out of bed and ambulate, clear liquids are started. On postoperative day 2, if the patient is passing flatus and tolerating regular diet, she is discharged home.

The standard of care was followed in this case. The admission was medically necessary and should be approved based on Milliman Care Guidelines (MCG) Laparotomy. However, it is unclear why the patient was not discharged on post-operative day 3 as nothing was done in the hospital that day.

Based on the above, the insurer's denial must be overturned in part. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The medical necessity for an inpatient hospital admission is substantiated. However, continuous stay for the last 24 hours of admission was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient is a man with non-valvular atrial fibrillation, non-alcohol related cirrhosis with esophageal varices, and diabetes. He is at high risk of bleeding. A cardiac computed tomography (CT) and echocardiogram did not show left atrial appendage (LAA) thrombus. In this circumstance, it has been concluded by a non-implanting physician that implantation of a left atrial appendage occluder (LAAO) would be a preferable approach to continuing Xaralto to prevent a stroke. The issue under review is whether the requested procedure is likely to be more beneficial than standard treatment(s). The health plan's determination is overturned in part.  The procedure, LAAO with the Watchman is appropriate in this patient as described above but full admission is not.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Inclusion Body Myositis
Treatment: Durable Medical Equipment (wheelchair and/with power recline, power seat lift, bag hooks, and elbow pads)
The insurer denied durable medical equipment (wheelchair and/with power recline, power seat lift, bag hooks, and elbow pads).
The denial is partially overturned.

The patient is an adult female with a medical history of inclusion body myopathy or myositis. Other medical history is notable for diabetes mellitus type II, anxiety, and hyperlipidemia. The patient currently uses a power wheelchair with power tilt and recline, power elevating leg rests, and power seat lift. A power mobility assessment indicated that the patient is non-ambulatory and cannot propel a manual wheelchair. The patient has scoliosis and lacks the upper extremity strength to perform pressure relief. The patient requires maximum assistance for transfers and performing daily activities. She is noted to have 2/5 strength in the upper and lower extremities. The requested group 3 power wheelchair was considered not medically necessary per guideline policy with the rationale that it exceeds the needs of the patient, and the patient does not require power recline, power seat lift, bag hooks, and elbow pads. This decision is being appealed.

The group 3 power wheelchair with power tilt and recline, power seat elevator and elbow pads are medically necessary. However, the bag hooks for the power wheelchair are not medically necessary.

The patient is non-ambulatory and cannot use a cane or walker for mobility. She cannot 
functionally propel a manual wheelchair due to upper extremity weakness. The patient cannot operate a power scooter due to impaired sitting balance and upper extremity strength. She requires a power wheelchair for mobility and accomplishing daily activities. She requires a group 3 power wheelchair given the complexity of her inclusion body myositis and that she requires multiple power components to meet her seating and mobility needs. The patient requires power tilt and recline given that she has 2/5 motor strength in the upper extremities and cannot perform pressure relief. Typically, a power seat elevator is not indicated in patients who are not independent with transfers to and from the power wheelchair with the assistance of a power seat lift. However, the documentation indicates that this significantly improves the patient's and the patient's caregivers' ability to transfer and allow access in the home for performing daily activities given that a Hoyer lift is not accessible or usable. Therefore, it can be considered medically appropriate for her condition. The elbow pads are medically necessary to support the patient's arms and allow appropriate pressure relief given her upper extremity weakness. The bag hooks for the power wheelchair are not medically necessary because they are not medical in nature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia
Treatment: home health care
The insurer denied Consumer and Self-Directed Personal Assistance Service, 24 Hours per Day, 7 Days per Week (Split-Shift). The health plan's determination is overturned in part.  

This is a case review for a female with medical history notable for Alzheimer's dementia, chronic kidney disease, heart failure, and osteoarthritis. The patient's physician provided a letter of support for this appeal. The letter states that the patient lives alone and that her multiple medical conditions have significantly worsened. She has advanced dementia and is unable to communicate her needs. She has advanced hypertensive heart and kidney disease. She is dependent on others for transfers, ambulation, and position changes. She is incontinent of bowel and bladder and requires frequent diaper changes. Her family has been privately paying to allow the patient to have 24-hour per day coverage, but they have run out of money and can no longer afford to continue to do so. The physician reports that it is necessary for 24-hour care to continue for the patient.

Consumer and Self-Directed Personal Assistance Service24-hour live-in care is medically necessary for this patient.
The physician notes and the Uniform Assessment System (UAS) both demonstrate that the patient requires hands-on assistance for all activities of daily living including eating, transfers and toileting. She is incontinent of both stool and urine with frequent episodes that will require assistance with changing. The patient's personal care needs are expected to be continuous and unscheduled throughout the day and occasionally at night as well. The task tool can be useful as a starting approximation for patient's personal care needs, but when care needs are expected to be continuous throughout the day and night, the task tool cannot be relied upon as the final determining factor in the number of hours awarded to the patient. The patient will require 24-hour care to address her personal care needs. Therefore, a 24-hour live-in personal care aide is medically necessary and appropriate for the patient.
The documentation provided does not demonstrate the medical necessity for split shift care. Split shift care is appropriate when a live-in personal care aide cannot receive adequate rest each night, including at least one 5-hour window of uninterrupted rest. There are no overnight care logs provided for review, and no evidence that the patient has care needs that would preclude adequate rest for a live-in aide.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decay

Treatment: D2750 White Glass with High Gold Content Crown, Tooth 14, D2750 White glass with High Gold Content Crown, Tooth 15

The insurer denied: D2750 White Glass with High Gold Content 
Crown, Tooth 14, D2750 White glass with High Gold Content Crown, Tooth 15

The denial is partially approved.

The patient is an adult female. The request is for new (replacement) crowns on teeth #14 and #15. The patient's provider notes that there is recurrent decay under the crown margins, and the gums are being irritated. The health plan denied coverage of the request due to decay not being found. The denial is being appealed.

The requested health service is medically necessary, in part.

Specifically, the requested health service is medically necessary for tooth #15, but the requested health service is not medically necessary for tooth #14. The X-rays are helpful in determining need for new crowns. However, the photos do not have the correct angle in the mouth and are not close enough to the crown margins to show any supposed recurrent decay at the margins. The photos are taken too far away from the tooth to determine if decay is present at the margins. Decay is seen on the X-rays under the distal margin of the crown on tooth #15. A new crown will be needed for tooth #15. No decay is seen on any X-ray of tooth #14. Also, no decay is seen at the margins of the existing crown on the poor-quality photos of tooth #14. A photo taken parallel with the crown margin may show the reported decay. The angle in the presented photos makes it hard to see the area in question. It is hard to determine if the dark area under the crown on tooth #14 is decay in the photos presented. Therefore, the requested health service is medically necessary for tooth #15, but the requested health service is not medically necessary for tooth #14.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pelvic inflammatory disease
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission. 
The denial is modified.
	
The patient is a female who presented to the hospital complaining of abdominal pain, vaginal discharge, and fever. Temperature was 102.2. Abdominal exams show abdominal tenderness in the right lower quadrant suprapubic area and left lower quadrant. Pelvic exam shows significant cervical motion tenderness. She was admitted with a diagnosis of pelvic inflammatory disease (PID) and maintained on cefoxitin and doxycycline. She responded well to treatment and was afebrile 24 hours after admission.

However, the patient was noticed while admitted having hepatosplenomegaly and anemia. She was kept in-house for completing the work-up of hepatosplenomegaly. She was to start iron supplements, finish antibiotics and follow up with primary care physician and hepatosplenomegaly as an outpatient. 

Most females with PID can be safely treated in outpatient settings. Indications for hospitalization and parenteral antibiotics include:

1) Severe clinical illness (eg ["for example"], fever greater than or equal to 38.5 [degrees] Celsius [101Fahrenheit], nausea and vomiting) 2) Complicated PID with pelvic abscess (including tubo-ovarian abscess) 3) Possible need for invasive diagnostic evaluation for alternate etiology (eg, appendicitis or ovarian torsion) or surgical intervention for suspected ruptured tubo-ovarian abscess 4) Inability to take oral medications 5) Pregnancy 6) Lack of response or tolerance to oral medications 7) Concern for nonadherence to therapy.

This patient has nausea and vomiting with concern about her ability to take oral medications. In addition, there was concern for nonadherence to therapy as she has been seen three times for the same condition.

Based on the above, and due to the elevated temperature and severity of the pain, admission was medically necessary. However, by the third day, the patient was afebrile and stable and could have been discharged on oral antibiotics. Note that the workup for anemia and hepatosplenomegaly could be performed as an outpatient.

The hospital admission for the initial two days is considered medically necessary for this patient. Continuous admission for the next two days was not. 

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

The insurer's denial of coverage for the hospital admission is modified. Medical necessity is partially substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  GERD.
Treatment:  Esophageal surgery and inpatient stay.  

The insurer denied the Esophageal surgery and inpatient stay.  The denial is overturned.

The patient is a with longstanding gastroesophageal reflux disease (GERD).  He has failed medical therapy.  He takes daily famotidine and lansoprazole.  He has tried multiple other medications.  He remains symptomatic despite twice a day (BID) proton pump inhibitors (PPI) and famotidine in the evening.  He has a normal esophageal manometry.  He has a DeMeester Score of 127.6, indicating very abnormally high esophageal acid exposure due to Gastroesophageal Reflux Disease.  Upper endoscopy revealed a small hiatal hernia, mild inflammation in the gastric antrum.  Esophagram revealed severe Gastroesophageal reflux.  
 
This patient suffers from GERD.  Even with BID PPI and H2 blocker, there is refluxing gastric contents.  Surgical therapies exist that resolve this very well.  Without LINX procedure, a Laparoscopic Nissen Fundoplication (LNF) would have been recommended.  Other techniques have been tried endoscopically and otherwise, but none have been able to demonstrate long term efficacy and safety.  The side effects of LNF make it a less than ideal operation.  LINX is an operation that is less disruptive to the normal anatomy, has been shown to be effective at reducing reflux episodes to a physiologic level, and has been shown to dramatically improve patient satisfaction long term.  It is approved by the FDA.  There is published data on patients, who have had the device for six years, showing a very low complication rate and a high resolution of GERD.  The standard of care is to perform this operation as an inpatient stay in order to provide adequate anti emetics, pain control, hydration, to ensure the safe recovery of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease, hypertension and osteoarthritis

Treatment: personal care assistant (PCA) services to 24 hours/day split-shift service

The insurer denied coverage for personal care assistant (PCA) services to 24 hours/day split-shift service

The denial is modified.

 
This is an elderly patient with coronary artery disease, hypertension and osteoarthritis.  She lives alone in a 1-bedroom apartment. The insured approved PCA services 12 hours/day, 7 days/week and the request is for 24 hours/day split shift.  

The Uniform Assessment System (UAS) was reviewed. The patient's cognition is described as minimally impaired. She is totally dependent to maximal assistance for her Instrumental Activities of Daily Living (IADL) tasks including ordinary housework, meal preparation and shopping. Extensive assistance is needed for bathing, dressing, personal hygiene, locomotion, ambulation and toilet transfer/use. She is frequently incontinent of bladder and continent of bowel. Limited assistance is needed for bed mobility and eating. She reportedly fell and loss consciousness at her grandson's house 1 month prior. There were no reported falls in her home over the prior 90 days. Her functional ability has decreased compared to the previous UAS report. The patient's cognitive and functional deficits are not at a level or unpredictable as to require the requested PCA services 24 hours/day (split shift). Based on the records reviewed, a live-in PCA is more appropriate as they are likely capable of providing for the patient's functional needs with the ability to consistently obtain uninterrupted 5 hours of sleep. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained at home by increasing PCA services to 24 hours/day, 7 days/week (live-in).

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 increase in personal care assistant (PCA) services to 24 hours/day split-shift services is not substantiated. However, increasing PCA services 24 hours/day (live-in) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

The patient with a past medical history significant for diabetes mellitus type 2, hypertension, alcohol dependence, and severe depression complicated by prior suicide attempt, was brought by medics to the Emergency Department for evaluation due to active suicidal ideation in the setting of acute alcohol intoxication.
Apparently, the patient had recently completed an inpatient rehabilitation program but relapsed on alcohol and had been drinking heavily and told friends and family that the patient wanted to self-harm. The patient had a history of multiple acute inpatient psychiatric hospitalizations for suicidal ideation and previously attempted to commit suicide by jumping out of a 16-story hospital window.

Laboratory studies demonstrated that the sodium was 135, potassium 3.3, chloride 95, bicarbonate 26, blood urea nitrogen (BUN) 19, creatinine 0.71, and glucose 157. Liver function tests were unremarkable. White blood cell count was 4.3, hemoglobin 11.9, hematocrit 36.9, platelets 18. An electrocardiogram demonstrated normal sinus rhythm with QTc prolongation measuring 492 milliseconds. The chest radiograph demonstrated no acute findings. In the emergency department, the patient was treated with intravenous fluids, intravenous lorazepam 2 milligrams (mg), and started on continuous 1:1 observation.
The patient was admitted to the hospital with alcohol intoxication with symptoms of alcohol withdrawal. The patient was also diagnosed with thrombocytopenia, which was attributed to myelosuppression due to the alcohol abuse. Another clinical problem was mild hypokalemia, and therefore the patient received potassium supplements.
At the time of admission, Clinical Institute Withdrawal Assessment (CIWA) score was 0. Subsequently, it was documented that the CIWA score went up to 11. During the hospital stay the patient was treated for alcohol intoxication and subsequently for alcohol withdrawal. The paitent received treatment with tapering doses of Ativan.

In the hospital, the patient was seen by a psychiatrist. When seen by a psychiatrist, the patient denied any suicidal or homicidal ideation. However, after the assessment, the psychiatrist recommended continuation of one-on-one observation. The patient was also seen by a hematologist/oncologist because of the thrombocytopenia. Apparently, the patient did not have any signs of bleeding, therefore no transfusion of platelets was recommended. The patient was seen by a cardiologist, who listed the patient's medical problems as diabetes, prolonged QT interval, and hypertension. In the plan section of the consultation note, there was no plan formulated. The patient underwent a stress test, which was negative. During the hospital stay the patient continued to be seen by a psychiatrist and was cleared for discharge.

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

In this clinical case, the patient had a number of psychiatric conditions including alcoholism, depression, suicidal ideations,