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

Diagnosis: abdominal pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission. 
The health plan's determination is overturned in part. 

The patient is a female with past medical history (PMH) of GAD (generalized anxiety disorder), asthma, diabetes mellitus type 2 (DM2), gastroesophageal reflux disease (GERD), HLPD (hyperlipidemia), hypertension (HTN), and post-traumatic stress disorder (PTSD) who was admitted with complaints of abdominal pain associated with nausea, distention, and constipation. Vital signs were notable for HTN. Physical exam was notable for no apparent distress (NAD), abdomen soft with mild diffuse tenderness without guarding or rebound. Lab work was unremarkable on admission. A computed tomography (CT) scan showed no acute pathology. The patient was diagnosed with abdominal pain and treated with proton pump inhibitor (PPI).

The initial dates of service were appropriate for the lower level of care. However, an inpatient admission was medically necessary for the final 3 days of the admission. The patient was initially admitted, but subsequently her lab work demonstrated significant acute kidney injury with an increase of creatinine from 0.6 to 3.2, which demonstrated a substantial decrease in glomerular filtration rate (GFR), above a 70% reduction. The patient required close monitoring for adverse sequela such as electrolyte abnormalities and telemetry for arrhythmia monitoring. Given the severity of the acute kidney injury (AKI), this patient was a poor candidate for observation dehydration care. In addition, given this patient's abdominal complaints, she was a poor candidate for oral hydration therapy, another indication that an inpatient level of care was required for safe treatment. The patient did not develop the severe AKI until day 5, when the inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart failure, legally blind, rheumatoid arthritis and ulcerative colitis

Treatment: Personal care services (PCS) 24 hours a day, 7 days a week (split shift) for a total of 168 hours per week

The insurer denied coverage for personal care services (PCS) 24 hours a day, 7 days a week (split shift) for a total of 168 hours per week

The denial is modified

 
This is an elderly patient with chronic medical problems including heart failure, legally blind, rheumatoid arthritis and ulcerative colitis.  She lives with her daughter and son-in-law in a private residence.  The insurer approved personal care services (PCS) 10 hours/day, 7 days/week for a total of 70 hours/week.  The request is for PCS 24 hours per day - 7 days per week (12 hour split shifts) for a total of 168 hours per week.

The patient's cognition is described as "moderately impaired."  She is totally dependent for much of her Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping.  She is also reportedly totally dependent for bathing, lower body dressing, locomotion, and toilet transfer/use.  She is frequently incontinent of bowel and bladder.  Maximal assistance is reportedly needed for personal hygiene, upper body dressing, eating and bed mobility.  She has reportedly fallen twice over the past 90 days.  

However, the patient's functional impairments are not at a level of unpredictable as to require the requested PCS 24 hours/day (split shift).  In fact, the physical therapy treatment notes from the skilled nursing facility, documents the patient's higher level of function.  She required only contact guard assistance and minimal assistance for bed mobility and transfer activities (locomotion), respectively.  She was also able to ambulate 75 feet with contact guard assistance.  According to the occupational therapy treatment notes, the patient required only supervision for personal hygiene and contact guard assistance for (upper and lower body) dressing.  Toileting was also at the contact guard level of assistance (not the reported total dependence).  

The patient may benefit from monitoring for safety; particularly due to her reported cognitive deficits and vison impairment  However, PCS for companion care or safety supervision without the direct provision of activities of daily living (ADL) task assistance is not a covered service.  Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained at home by modestly increasing PCS to 12 hours/day, 7 days/week totaling 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 services (PCS) 24 hours a day, 7 days a week (split shift) for a total of 168 hours per week services is not substantiated. However, increasing PCS to 12 hours/day, 7 days a week for a total of 84 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral Palsy. 
Treatment: Durable Medical Equipment (Transit Option, Canopy and Basket) (Pre-Service). 
The insurer denied the Durable Medical Equipment (Transit Option, Canopy and Basket) (Pre-Service). 
The denial is overturned, in part. 

This is a child with history of seizure disorder and developmental delays. The child has been diagnosed with microcephaly with hypotonia. The child has been receiving pediatric rehabilitation services at school and has been followed by the pediatric physiatrist and neurologist. The child has been recommended to use the Convaid adaptive stroller, gait trainer and activity chair. A detailed letter of medical necessity has been provided in support of the Convaid Cruiser with accessories. The health plan denied coverage for the following components/accessories: Cruiser Transit Option CX14, Deluxe Canopy with Side Windows CX14 and Underseat Storage Basket CL13/16T. 

Yes, in part, the proposed durable medical equipment is medically necessary. The transit option and canopy are medically necessary; the basket is not medically necessary. 

Accessory items including a transit option, canopy and basket were previously deemed not covered on the basis that they were not medically necessary for home use. However, the submitted medical records as well as substantiated clinical evidence identify important needs related to this child which should be taken into consideration such as transportation safety to and from the physician's office/school and environmental exposure related to seizure history/medication use at the time of transport. 

As detailed by the physical therapist, the proposed transit option is required for safe transportation when attending various doctor's appointments and community activities, as well as on the school bus when attending school. While this feature may not be required for daily use, it is essential to comply with safety standards. The canopy is being requested for protection from direct sunlight for extended periods of time; this is based on the child's history of seizures as well use of medication that can had adverse side effects if exposed for prolonged periods. This item is appropriate to prevent adverse health events. The last item, the basket, is being requested to carry the child's medications during transport. However, this item would not be medically necessary as it is more of a convenience item. Medications can be carried by other means; it is not a requirement to carry them in this storage basket. 

The transit option and canopy should be considered as essential items that have been specifically requested by qualified healthcare providers to ensure safety of this vulnerable child. The above-mentioned accessories should be viewed as sound and reasonable options for this very involved child with neurological impairment requiring a safe transportation option and prevention of adverse health events.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Pneumonia.
Treatment:  Inpatient admission.
The insurer denied coverage for inpatient admission.  
The denial is modified.
 
Patient is an adult, who has multiple medical problems - hypertension, hyperlipidemia, Allergic bronchopulmonary aspergillosis, and chronic lymphedema. The patient was previously hospitalized for pulmonary embolus. Subsequently he was admitted for treatment of Covid for 3 days. Patient was discharged home earlier on the day of admission. He had refused sub-acute rehabilitation. While at home later in the day the patient felt weak and dizzy and was brought back to the hospital.

Vital signs at presentation Temperature 99 degrees F, Pulse 91, Respirations 18, Blood Pressure 94/64. Oxygen saturation on room air was 98% (percent). He was noted to have a doubling of his white blood cell count (WBC) from earlier that morning to 19. It was 9 at the time of discharge earlier that morning. There was significant worsening of his creatinine to 1.48. It was normal at the time of discharge. A chest x-ray was done, which revealed possible new right middle lobe opacity. The patient was admitted to the hospital for treatment of healthcare-associated pneumonia and acute kidney injury.

He was treated with intravenous (IV) fluids, and antibiotics were started. He was given aggressive hydration and started improving after initiation of treatment. The patient was seen by physical therapy and occupational therapy and was now agreeable for transfer to sub-acute rehabilitation. He was medically cleared for discharge to sub-acute rehabilitation by the fourth day of admission under review.

Thus, as of the fourth day of admission under review, he was eligible for a lower level of care and no longer required acute inpatient level of care.

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. Allow acute inpatient care for first three days, but uphold denial of acute inpatient care for the remainder of the hospital stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Glaucoma, gait abnormality, hypertension, urine
incontinence
Treatment:   Increase Consumer Directed Personal Assistance Services to 56 Hours per Week
The insurer denied the   Increase Consumer Directed Personal Assistance Services to 56 Hours per Week.
The denial is overturned, in part. 

The patient is a female with a history of Glaucoma, Gait abnormality, Hypertension and Urinary Incontinence. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 56 hours/week Consumer Directed Personal Assistance Services to offer increased activities of daily living support.

Yes, in part.  The proposed treatment of 56 hours/week Consumer Directed Personal Assistance Services is medically necessary, in part. Specifically, Consumer Directed Personal Assistance Services are medically necessary at 38 hours per week.

An assessment of the patient's functionality and ability to perform activities of daily living was completed and revealed that 38 hours/week Personal Assistance Services is sufficient to  meet the patient's current needs. However, the health plan only approved 34 hours. Based on the results of this assessment, the 38 hours/week Consumer Directed Personal Assistance Services are medically necessary. Specifically, this assessment revealed that the patient is currently receiving skilled nursing services 2x (times)/weekly and that her daughter performs wound care for her sacral pressure ulcer. In addition, she is currently receiving Physical Therapy services. In addition, she has a bedside commode for use during the day and night.

There is no additional documentation which demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, while the proposed treatment 56 hours/week Consumer Directed Personal Assistance Services is in excess of the patient's current medical needs, the currently approved plan of 34 hours/week is insufficient to meet the patient's needs. 38 hours/week of Consumer Directed Personal Assistance Services are medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lupus flare versus atypical preeclampsia

Treatment: inpatient hospital admission

The insurer denied coverage inpatient hospital admission. The denial was modified.

This patient is a female who presented at 31.5 weeks gestation; with a 3 day history of bilateral lower leg swelling and headache with blurred vision not relieved by Tylenol. The patient has a past medical history of Systemic Lupus (SLE) and seizures in 2 previous pregnancies. Preeclampsia was ruled out based on lack of elevated blood pressure and lack of proteinuria and normal laboratory evaluation. There were concerns about possible deep vein thrombosis (DVT). The patient was admitted for observation, management of her headache and for Doppler studies. Her vital signs were stable. There was no evidence of SLE flare-up. The patient was seen by Maternal Fetal Medicine, Rheumatology and Neurology. Neurology was concerned about seizures and recommended oral magnesium. The Rheumatology team did not feel that this was an SLE flare-up. Her symptoms improved and she was discharged.

The patient presented with complaints of headaches and leg swelling. Her blood pressure was not elevated. There was no vaginal bleeding, no uterine contractions and no ruptured membranes. There was no evidence of fetal compromise. Preeclampsia refers to the new onset of hypertension and proteinuria or hypertension and significant end-organ dysfunction with or without proteinuria after 20 weeks of gestation in a previously normotensive woman. So, based on this patient's presentation, she did not have preeclampsia. Because of her history of prior seizures, admission for close observation and neurology consult were medically necessary and so was the need to rule out deep vein thrombosis (DVT). However, as of a specified date, the patient was stable. Neurology recommended oral magnesium, preeclampsia and DVT had been ruled out, the patient was stable and she could have been discharged home and followed up as an outpatient. It is unclear why she was kept in the hospital for 2 additional days. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient with regard to the admission. The inpatient hospital admission from the dates specified is medically necessary for this patient. However, continuous admission from other specified dates was not medically necessary.  

The determination is modified. Based on the above, the medical necessity for the inpatient hospital admission from specified dates is not substantiated. Inpatient hospital admission from other specified dates is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease/GERD
Treatment: LINX Procedure and Full Hospital Admission
The insurer denied the LINX Procedure and Full Hospital Admission. The health plan's determination is upheld. 

The patient is a female with a history of gastroesophageal reflux. She is described as having gastroesophageal reflux disease (GERD) despite Dexilant 60 milligrams (mg) proton pump inhibitor (PPI) therapy.
A pH (potential hydrogen) study demonstrated abnormal acid exposure in the esophagus with a DeMeester score of 21.8. Esophageal motility study was normal. She has a body mass index (BMI) of 22. Upper gastrointestinal (GI) contrast study shows no hiatal hernia per the reading, although the surgeon describes a "tiny" hiatal hernia. An esophagogastroduodenoscopy (EGD) showed a normal esophagus and stomach. Distal esophagus biopsy showed no abnormal cells or esophagitis.
This review concerns the proposed LINX procedure and associated hospital stay for the treatment of her GERD.

The LINX procedure and Full hospital admission are not likely to be more beneficial than standard treatment for this patient's GERD. Current standard treatments include diet and behavior modification, PPI medication therapy, and surgical fundoplication. Numerous studies have evaluated the LINX procedure and found results for reflux control similar to surgery in the short term, but with unanswered concerns about longer term dysphagia and erosion.

Given a long history of late complications from encircling devices around the esophagus and gastroesophageal junction, there is reason for concern. As Kirkham writes in a 2020 systematic review, "Most studies on MSA (magnetic sphincter augmentation) lacked information about patient selection, governance, expertise, techniques and outcomes, or varied between studies. Currently, MSA is being used despite a lack of robust evidence for its effectiveness".
In summary, the proposed LINX procedure is not likely to be more beneficial than standard therapy, and may in fact be worse over the long term if late erosions and dysphagia manifest in longer term analyses.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder. 
Treatment: Nerve treatment tooth #11 and tooth #2, White glass with metal crown tooth #2. 

The insurer denied Nerve treatment tooth #11 and tooth #2, White glass with metal crown tooth #2. 

The determination is overturned in part. 

The patient presented for evaluation and treatment of teeth number (#) 11 and 2. Provided for review are previous letters of appeal and denial, full mouth radiographic images, explanation of benefits, and health plan language. At issue is the medical necessity of the planned treatment of root canal for tooth #11 and 2, as well as porcelain fused to metal crown for tooth #2. 

The requested services/treatment are medically necessary in part. 

For tooth #2, no, the requested health service/treatment of Nerve treatment tooth #2 and white glass with metal crown tooth #2 is not medically necessary for this patient. In regards to tooth #2 with the requested treatment of root canal therapy and porcelain fused to metal crown, the health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient. Tooth #2 does not have enough remaining tooth structure to support a crown nor any other restoration and has a hopeless prognosis. 

For tooth #11, the requested health service/treatment of Nerve treatment tooth #11 is medically necessary for this patient. This is a cuspid tooth. Tooth #11 has pulpal exposure and thus irreversible pulpitis. Tooth #11 also has enough remaining tooth structure to allow for restoration. In any situation where the patient has the diagnosis of irreversible pulpits, as long as the tooth is restorable, there is the requirement to treat the pulpitis through removal of the infected nerve, artery, vein, as well as the canal tooth structure, irrigate with sodium hypochlorite, and fill with gutta percha medicament as this is the only therapy that will treat the diagnosed pathology. This is a root canal. If the therapy is not done, the pulpal infection can spread to the surrounding bone, which can lead to the presence of abscess, with an array of sequential systemic sequela. Hence, based on the diagnosis of irreversible pulpits alone, the therapy of root canal therapy is indicated. 

The health plan's determination is overturned in part for allowance of #11 root canal therapy (it is not a molar it is a cuspid) and upheld for tooth #2 root canal (3330) and porcelain fused to metal crown (2751).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute respiratory failure, COPD.
Treatment Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned in part.

The patient has chronic obstructive pulmonary disease (COPD), Takotsubo cardiomyopathy and presented with dyspnea and a cough that began that morning. Emergency Medical Services (EMS) found she was saturating 84% on room air (RA). She was given dexamethasone and nebulizers and placed on a non-rebreather.
In the emergency department (ED), her temperature was 98.6 degrees Fahrenheit, blood pressure (BP) 204/102, heart rate (HR) 123, respiratory rate (RR) 26, SpO2 (oxygen saturation) 84% on room air (RA). She was ill appearing, wheezy, alert and oriented. Her white blood cell count (WBC) was 11.67, blood urea nitrogen (BUN)/creatinine (Cr) 7/0.5.
She was diagnosed with acute respiratory failure, acute chronic obstructive pulmonary disease (COPD) exacerbation and started on bi-level positive airway pressure (BiPAP), intravenous (IV) steroids, ceftriaxone and azithromycin, and nebulized bronchodilators.
She was feeling better, continued on antibiotics, steroids, and nebulizers, remained on BiPAP and was saturating well. She was doing much better, off BiPAP, saturating 96% on RA, with clear lungs, treatments continued. She remained stable, was felt ready to go home by the patient and team, and continued on treatments. She was feeling much better and wanted to go home. She was saturating well on RA. Treatments continued. She felt well, discharge was held up due to homelessness. She was treated with prednisone and Symbicort. She was feeling well, with no complaints, continued on prednisone and Symbicort. She continued to feel well and was discharged on prednisone.
At issue is the medical necessity of an inpatient stay.

An inpatient stay was medically necessary in part for the first three days of the stay but not after that.
The patient presented with dyspnea and was found to be in acute hypoxemic respiratory failure and acute respiratory distress requiring non-invasive ventilation. Disease this severe requires close inpatient monitoring to ensure the patient does not deteriorate and require endotracheal intubation. BiPAP for acute respiratory failure is an inpatient only treatment. Care on the first three days could not be provided on an outpatient basis. However, after that, she was feeling much better, was off BiPAP and supplemental O2, had clear lungs and on these days, she was much better, had recovered, and did not need inpatient only testing, monitoring, or treatment. Care could then have been provided on an outpatient basis as she had recovered from her severe illness.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Pancreatitis.
Treatment:  Inpatient Hospital Admission.

The insurer denied the inpatient hospital admission.  The denial is partially overturned.

The patient is an adult male with history of alcohol abuse and chronic pancreatitis, who presented with abdominal pain, nausea and vomiting (NV) and was found to have a lipase of 183. The patient was admitted, hydrated and treated with pain medication. On day # (number) 2, computed tomography (CT) scan of the abdomen and pelvis revealed acute pancreatitis. The patient was hydrated and monitored for alcohol withdrawal. Triglycerides were elevated, and he was treated with oral agents to lower them. On day #3, the patient was tolerating a diet and only had a mild tremor. There was no further vomiting. On day #4, the patient continued to improve. He was discharged on day #5.

The proposed inpatient hospital admission was medically necessary for days #1 and #2. However, the inpatient hospital level of care for days #3, #4 and #5 were not medically necessary.

On days #1 and #2 the patient had abdominal pain, a lipase elevation of greater than three times the normal and computed tomography (CT) findings of pancreatitis, and had vomiting, with an inability to tolerate oral intake or oral pain medication; criteria for acute inpatient hospital stay was medically necessary. However, on the remainder of the days, as the patient had no further vomiting, was tolerating oral intake, and had no evidence of alcohol withdrawal; he could have been discharged on oral pain medication, oral anxiolytics, and oral medication to treat his elevated triglycerides. Therefore, acute inpatient admission was medically necessary for the first 2 days. The patient was medically stable for discharge on day #3, and acute inpatient hospital stay was not medically necessary for the remainder of the inpatient days.