Persius/imr-appeals huggingface dataset:
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 overturned in part. The LINX procedure is indicated for this patient; however, a full inpatient admission is not.

This patient is a woman (body mass index (BMI) 22.5) who sought surgical evaluation for the condition of heartburn. This symptom of gastroesophageal reflux disease (GERD) persists despite use of prescription proton pump inhibitor (PPI) medication (Dexilant). She continues to have breakthrough symptoms. She has no dysphagia. The treating surgeon has proposed the LINX procedure with full hospital admission as treatment of GERD. This is the subject under review.

Based on the current evidence-based literature and the patient-specific objective clinical evaluation in this case, the LINX procedure is likely to be more beneficial than any standard treatment for this insured's condition of proven GERD. However, a full hospital admission is not indicated as this procedure could be appropriately performed at a lower level of care. The patient has symptoms of chronic GERD (heartburn). She has been appropriately evaluated with EGD (esophagogastroduodenoscopy) that showed normal esophagogastric anatomy. There is no contraindicating esophageal motor condition based on the esophageal motility study. There is confirmed pathologic esophageal acid exposure with elevated esophageal acid exposure over the course of a 96-hour pH (potential hydrogen) study. Finally, the patient does not have specific contraindication to implantation of the LINX device such as Scleroderma, suspected or confirmed esophagogastric cancer, prior esophageal or gastric surgery or endoscopic intervention, esophageal motor pathology, symptoms of dysphagia more than once per week, esophageal stricture or other gross anatomic abnormalities, esophageal or gastric varices, lactating, pregnant or plan to become pregnant, morbid obesity, or age < 21.
Therefore, based on the status of peer reviewed literature and adequate long-term follow up, specialty surgical society position statement affirmation regarding LINX and FDA approval, the LINX procedure is indicated in this case. However, this procedure could be performed at a lower level of care and does not require inpatient admission. A lower level of care would allow for provision of the operative intervention, post-surgical monitoring and care, and diet progression, including overnight observation if needed.
Appeal type: Medical necessity
Decision: Overturned

This is a patient  with a history of coronary artery disease (CAD), osteoarthritis, blindness, Alzheimer's disease, hypertension, cerebrovascular accident (CVA), and hearing loss. A change in her personal care aide service from 12 hours per day, seven days a week, for a total of 84 hours, to 24 hours a day, seven days a week, for a total of 168 hours is being requested. The patient's provider states that the patient's condition has deteriorated over the last six months. 
The health plan's determination is overturned in part. The requested number of hours is not medically necessary for the patient based on the general stability of her physical function. However, because her physical function has declined moderately compared to the prior evaluation, it would be reasonable and medically necessary to increase her support from 12 hours per day to 16 hours per day. This would reduce the fall risk for the patient and address the decline in some activities of daily living, such as toilet use.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender Dysphoria. 
Treatment: Surgical Services. 
The health plan denied mastectomy, nipple reconstruction, removal of excess skin. 
The health plan's determination is partially overturned. 

The patient is a female to male (FtM) transgender who has been on hormone therapy. They have been living and dressing as a male. They have dysphoria regarding breast appearance and cannot look at them in the mirror. Masculinizing chest surgery is recommended. The subject under review is the medical necessity for mastectomy, nipple reconstruction surgery, removal or excess skin.

The health plan's determination is overturned in part. 

Mastectomy and nipple reconstruction is medically necessary, removal of excess skin is not medically necessary. Codes 19303, and 19350 are medically necessary. Code 15839 is not medically necessary. Per the World Professional Association for Transgender Health (WPATH) "Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People" 7th Edition guidelines:
Criteria for Breast/Chest Surgery (One Referral)
Criteria for mastectomy and creation of a male chest in FtM patients:
1) Persistent, well-documented gender dysphoria;
2) Capacity to make a fully informed decision and to consent for treatment;
3) Age of majority in a given country (if younger, follow the standard of care [SOC] for children and adolescents);
4) If significant medical or mental health concerns are present, they must be reasonably well controlled.
Hormone therapy is not a prerequisite.
The patient meets these guidelines. He has well documented gender dysphoria and has the capacity to make an informed decision. He has been on hormone therapy for one year. He is the age of majority. He does not have significant mental health concerns at this time other than dysphoria regarding the breasts. A mental health professional has recommended the mastectomies and nipple reconstructions. Removal of excess skin is not medically necessary. Excess skin removal is not a standard or required procedure for gender transformation. Removal of excess skin is to improve appearance of the axillae and is not medically necessary. Code 15839 is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Mental Health
Mental Health: Inpatient

Diagnosis: bipolar disorder
Treatment: Inpatient mental health. The insurer denied the inpatient mental health stay. The health plan's determination is overturned in part. 15 days are medically necessary. 

The patient is a male with diagnoses of bipolar disorder (BPD) with psychotic features versus (vs.) schizoaffective (SCZD) disorder admitted to Behavioral Health Inpatient Treatment (BHIT).

The requested treatment of BHIT for 15 days is medically necessary. Discharge before this would be against this patient's best interests in view of his multiple psychosocial stressors, past history, and comorbid conditions. Poor social attachment is associated with increased suicide risk. This patient has multiple stressors which interact with his genetic predisposition to increase his suicide risk. This patient had a clear genetic predisposition in addition to multiple psychosocial stressors. The only acceptable goal for treatment of bipolar disorder is sustained euthymia, without psychotic features. Considering all his risk factors, it is medically necessary and reasonable to require several days of sustained improvement to avoid discharge premtaurely for this patient. The evidence from case notes supports sustained improvement, leading to the judgment that it would be in the best interest of the patient and in accord with current standards of best care that the patient be discharged on day 15. Discharge prior would have a high probability of relapse and the need for rehospitalization.
Appeal type: Medical necessity
Decision: Overturned

Schizophrenia 
Mental Health - Inpatient

The patient is a  male with a diagnosis of schizophrenia (SCZ). The question is whether continued inpatient stay (CIS) is medically necessary.  Case notes document that the patient suffer from chronic SCZ.  The admission of the patient to inpatient care was necessitated by worsening suicidal ideation (SI) for about two weeks, associated with intense auditory hallucinations (AH) including command hallucinations. Additionally, the patient experienced severe anxiety, depression, and paranoia.  He experienced insomnia and was amotivational.  He had been receiving clozapine as an outpatient but adherence to this medication is unknown.  He had been evaluated several times in the emergency room prior to the admission under review.  He suffered from loss of his job and was housebound with his mother.  After admission, the patient was treated with venlafaxine, trazodone, clonazepam and Clozaril.  The Clozaril was gradually increased.  A progress note indicates the patient no longer experienced auditory hallucinations and that his anxiety was decreased, and he had decreased beliefs that others were reading his mind.   With this lessening of psychosis, he had no suicidal ideation, from the available progress notes.  The day prior to discharge was he sleeping well, "feeling fine," without perceptual abnormalities. He was rational and participated in aftercare planning. 

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

The requested treatment of CIS was medically necessary for this patient, in part.  On the proposed last date approved by the health plan, the patient, if discharged, would have had  a high probability of requiring readmission or of self-harm.  The patient continued with auditory hallucinations, anxiety and paranoia.  While this represented a partial improvement, the patient would be at substantial risk if discharged.  He was chronically ill, and his illness represented a severe worsening of his chronic condition.  Progress notes document that he continued to experience thought broadcasting, paranoia, and delusions of reference.  A progress note indicates the patient no longer experienced auditory hallucinations beginning two days prior to discharge and that his anxiety was decreased, and he had decreased beliefs that others were reading his mind.  With this lessening of psychosis, he had no suicidal ideation, from the available progress notes.  The day prior to discharge he was sleeping well, "feeling fine," without perceptual abnormalities.  He was rational and participated in aftercare planning. Therefore, the patient could have been discharged one day prior to the actual discharge date.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Non-obstructive urinary retention
Treatment: Sacral neuromodulation
The insurer denied: Sacral neuromodulation
The denial is partially overturned.

The patient is a teenage female. Her history includes renal/bladder ultrasound demonstrated large bladder capacity and elevated post void residual (about 300cubic centimeters) 2 years ago. The patient was placed on timed voiding. The patient was seen 3 months ago and presented with urinary frequency up to every 30 minutes and leakage of urine if she could not get to the bathroom on time. This persisted despite a trial of oxybutynin 10mg (milligrams) XL (extended release) and 15mg (milligrams) XL (extended release). Two months ago, the patient reported frequency every 45 minutes, straining to void, nocturia 4 to 5 times per night. The patient had a urodynamic study that demonstrated no detrusor overactivity, unable to void with 
bladder filled to 500ml (milliliters). A uroflow prior to the urodynamic study demonstrated voided volume of 548ml (milliliters), extremely elongated flow curve and postvoid residual of 160ml (milliliters). It was recommended that she perform Clean intermittent catheterization, but due to anatomic abnormalities narrow introitus, she was unable to perform clean intermittent catheterization by herself and thus sacral neuromodulation was recommended. The request is for a trial and potentially permanent placement of sacral neuromodulation. The service was denied coverage by the health plan as not medically necessary due to lack of documentation of more than 
50% improvement with trial. The denial is being appealed.

The requested health service is medically necessary, in part.

Specifically, a trial of sacral neuromodulation is medically necessary for this patient, though permanent placement is not medically necessary at this time. The information provided demonstrates that the patient meets the criteria for a trial period of sacral neuromodulation. She has non-obstructive urinary retention, and her symptoms have been present for at 
least 12 months, she has no documented neurologic cause, and she is unable to perform clean intermittent catheterization due to anatomic abnormalities. Thus, the patient meets criteria for a trial of sacral neuromodulation. However, placement of permanent device is not medically necessary at this time, as the patient does not have documentation of response to a trial period.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression.
Treatment Inpatient mental health.
The insurer denied the inpatient mental health stay. The health plan's determination is overturned in part. 14 additional days are medically necessary. 

This case involves an adult male who called 911 and was brought by emergency services to the emergency department and admitted for acute inpatient psychiatric treatment. The patient had become increasingly depressed with suicidal ideation, and deterioration in functioning culminating in his presentation to the emergency department and admission after medical screening. He had a history of mood disorder best characterized as bipolar mood disorder with severe depressive episodes and psychiatric treatment with therapy and medications. He had co-occurring substance use disorders including opioid use disorder in treatment with methadone maintenance, and use of cannabis and benzodiazepines.

14 additional days are medically necessary. The patient's presentation and clinical features included severe symptoms of mood disorder, suicidal risk, and deterioration in functioning in the context of substance use disorder. The patient remained at risk for relapse and suicidal behavior during the time interval under review to day 14 when he no longer represented a safety concern and was functioning better with improved symptoms and medication adherence. Additionally, a safe and clinically appropriate discharge plan and disposition was critical in this case to prevent re-hospitalization or immediate relapse. The patient could not have been expected to participate in treatment at a lower level of care in this case scenario until he had stabilized. In this regard, the patient no longer warranted continued acute inpatient level services from day 14 forward.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infertility
Treatment: IVF and embryo transfer
The embryo transfer was medically necessary; however, the IVF was not medically necessary.

The patient is a female with a diagnosis of infertility.  The patient has undergone an IVF (in vitro fertilization) cycle with physician A earlier, which resulted in a chemical pregnancy.  No details about this cycle are available. 

The patient underwent another IVF cycle with physician B with ICSI (intracytoplasmic sperm injection) and PGS (preimplantation genetic screening).  She had five euploid embryos.  One embryo was transferred.  She had two more frozen embryo transfers (no clinical documentation was submitted about how many embryos were transferred).  None resulted in a live birth. 

The patient is requesting coverage for the embryo transfer cycle that took place between the dates of service under review.

This patient has a diagnosis of infertility and is eligible for infertility treatments.  The patient underwent an IVF cycle that resulted in five euploid embryos.  The next step according to standard of care is to proceed with a frozen embryo transfer.  The patient had three consecutive frozen embryo transfers performed using the euploid embryos from her IVF cycle.  Since she did not conceive after the first transfer, a second transfer was necessary, and since she did not conceive after the second transfer, a third transfer was also necessary.

Note that the patient did not undergo any additional IVF cycles while she had frozen embryos.  She was managed according to the ASRM (American Society for Reproductive Medicine) recommendations, which are to use her frozen embryos prior to undergoing another IVF cycle. 

Therefore, since there are frozen embryos still available, the embryo transfer is medically necessary.  A frozen embryo transfer is the standard of care in this patient's case.
However, IVF would not be indicated at this time.

Note: there was no documentation that IVF was performed on these dates of service.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Aspirin overdose, toxic encephalopathy, hypertension and a urinary tract infection with suicidal ideation
Treatment: Inpatient Hospital Admission

Summary: This patient with a past medical history of alcohol and illicit drug use was brought to the Emergency Department (ED) by Emergency Medical Services after she reported taking 60-80 tablets of aspirin with a suicidal intent. The patient has other past medical history of diabetes mellitus and depression. EMS found the patient combative with a blood pressure of 200/90. In the ED, the patient was complaining of chest pain/abdominal pain. She was hypertensive to 191/86 mm Hg. The patient was talking, but not making sense. A salicylate level was elevated to 36.7. The white blood cell (WBC) count was 20.6K. A urinalysis revealed leukocytes and bacteria. Urine toxicology was positive for opiates. A troponin was negative. An electrocardiogram showed sinus tachycardia with occasional premature ventricular contractions. The patient was placed on 1:1 observation due to suicidal ideation. Intravenous (IV) hydration and Zofran were given. The patient was not cooperative with treatment and was removing lines. The patient required multiple reinsertions of her IV device. The patient was admitted to the Intensive Care Unit for aspirin overdose, toxic encephalopathy, hypertension and a urinary tract infection (UTI) with suicidal ideation. As per poison control recommendations, the patient was to be on sodium bicarbonate (NaHCO3) infusion until two consecutive levels of aspirin were below 30. The patient was treated with Xanax and Haldol for agitation.

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

The denial was partially approved. Based on the patient's presentation with salicylate overdose with suicidal intent and agitation, altered mental status with likely toxic encephalopathy and possible UTI, an admission was appropriate. The patient was seen by Infectious Diseases. They recommended Vantin orally for the UTI. The patient's mental status remained altered after admission. She was talking, but not making sense. She was on oral antibiotics and blood pressure medications, in addition to IV fluids and proton pump inhibitor. The patient had been seen by Psychiatry who recommended 1:1 observation. The subsequent days of the admission were denied because the patient was alert and oriented x3. She denied any complaints, and was in no acute distress. The patient was on oral medications and hemodynamically stable. Labs were unremarkable. This patient did not need further acute medical admission. The patient was stable for transfer to Psychiatry. The patient denied any symptoms other than depression. She was afebrile and hemodynamically stable. There was no acidosis or hypoxia.
Appeal type: Medical necessity
Decision: Overturned

The patient, presented to the dental provider's office for evaluation and treatment of tooth #4,18,19,20,21, and 22. Radiographic images show that #18 and 19 have extensive decay involving the cusps. The patient is missing tooth #21 while teeth #20 and 22 have no evidence of decay. . The health plan's determination of medical necessity is overturned in part. The requested health service/treatment of porcelain fused to base metal crown (2751) for teeth #18 and 19 is medically necessary. For sites #20 and 22, there is no evidence of decay, there is only a missing tooth. As such, the treatment of a fixed partial denture is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorder 
Treatment: Pharmacy/Prescription Drugs (Dupixent) 
The insurer denied Dupixent. 
The denial is partially overturned.

The patient is a male with severe atopic dermatitis, greater than 10% (percent) body surface area (BSA) and requiring hospitalization in the past. The patient was treated with topical steroids, topical Tacrolimus, and Eucrisa. The patient also has allergies and asthma and takes medications for these. The patient's provider is requesting Dupixent. The health plan requires at least 10% BSA and a trial and failure to Eucrisa and Tacrolimus. The request was denied as a recent patient weight was not submitted. The subject under review is the medical necessity for Dupixent.

The health plan's determination is overturned in part. The requested drug is medically necessary; however, the health plan is correct in that a current patient weight is required in order to properly administer the medication. The treatment with Dupixent is medically necessary for this patient. The patient has tried and failed Eucrisa and Tacrolimus, however the dosing for Dupixent cannot be determined without a patient weight. The medication is medically necessary, but a current weight will be required in order to calculate the medication dosage.