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

Diagnosis: Congenital malformation of optic disc, seizure
disorder, and expressive language disorder
Treatment: Consumer Direct 1 Client 105 Hours/Week
The insurer denied the Consumer Direct 1 Client 105 Hours/Week
The denial is partially overturned. 

The patient is a female child with medical history significant for blindness secondary to congenital malformation of optic disc, seizure disorder, and expressive language disorder. She is able to creep/crawl and play with toys. She remains incontinent of bowel and bladder. She is non-verbal and receives speech and language therapy three times a week. She is legally blind, receiving services for the blind. She takes two anti-convulsant medications.

According to an assessment, the patient has occasional breakthrough seizures, most recently associated with vomiting. She tolerates a mechanical soft diet. She does not sleep through the night, waking up several times screaming and taking one to two hours to fall back asleep.

The patient lives with her parents and two siblings. Her mother does not work outside of the home. Her father works full time outside of the home. Both parents are capable caregivers.

The patient's home health needs include assistance with all activities of daily living (meals, toileting, bathing, laundry), monitoring for seizure activity, and maintenance of safety due to age and blindness. Some of her needs such as toileting and bathing are consistent with typical same age children and not associated exclusively with her condition.

Yes, in part. The Consumer Directed Personal Assistance Sercvices Client 105 Hours/Week are medically necessary, in part. Specifically, Consumer Directed Personal Assistance Services are medically necessary 56 hours per week (8 hours/night 7 nights per week).

This child has a number of needs as a result of and in addition to her seizure disorder and blindness. She is non-verbal and ambulatory by creeping/crawling. She is blind and must be monitored for safety at all times. She awakens frequently at night and stays awake for extended periods of time. She has occasional breakthrough seizures, but it is unclear if she requires rescue medication or if they resolve on their own. A number of her needs are consistent with same age typical children, including bathing, toileting, meal preparation. Needs unique to her condition include breakthrough seizures, altered fine and gross motor skills, and poor sleep hygiene.

Based on the documentation provided, home health nursing services are not medically necessary during the day. The mother is at home full time and the father, who works outside of the home full time, is available to participate in care before and after work. However, this child requires constant supervision at nighttime to maintain safety, prevent injury, and address issues such as eating and toileting. Based on this child's clinical condition, the current standard of care, and the documentation provided, the requested services are medically necessary and appropriate 8 hours nightly 7 nights/week, for a total of 56 hours per week.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Phencyclidine (PCP) induced psychosis.
Treatment:  Inpatient Mental Health Stay.

The insurer denied the inpatient mental health stay.  The health plan's determination is overturned in part. Two additional days were medically necessary. 

The patient is a male with a diagnosis of hallucinogens (phencyclidine) (PCP) induced psychosis.  Case notes document that the patient was admitted via the Emergency Department (ED) because of his aggressive and dangerous behavior in the community.  When he could not be stabilized in the ED, he was admitted.  The patient has a history of substance use disorder, primarily PCP.  He has two prior arrests, one for domestic abuse and one for substance use.  He had functional impairment and high social stressors prior to admission, specifically lack of family support, residing in a shelter, and no college education.

In the ED, he was noted to be responding to internal stimuli.  He was screaming and making inappropriate sexual gestures.  He had poor impulse control, disorganized behavior, paranoid delusions, as well as poor insight and poor judgment.  On the inpatient unit, he was treated with Haldol, Cogentin, risperidone, trazodone, and Ativan as needed (prn).  In addition, he received supportive psychotherapy and discharge planning.

The Adult Inpatient Mental Health Treatment for Adults (AIMHTA) for 2 additional days is medically necessary for this patient. 

Based on a review of hospital progress notes, the patient could not be safely discharged and with good medical judgment on day 2 recommended by the health plan.  The patient had clearly improved in several parameters, but was still experiencing auditory hallucinations as he had also experienced prior.  PCP produces schizophrenia type symptoms.  PCP induces psychotic symptoms and needs to be treated as a psychosis.  PCP psychosis is treated with neuroleptics and anti-anxiety agents, as was done with this patient.  The experience of continuing auditory hallucinations supports the fact that the patient was still under the influence of his PCP use disorder.  This symptom would entail a high probability that he would need to be readmitted, or would be of risk to others, and possibly to himself, if discharged on the date in question.  The lack of new clinical information would support the probability that there was no new adverse symptomatology in the patient.  Therefore, the patient could be safely discharged on the 2nd day with good medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth decay
Treatment: Crown (D2740) on Tooth Numbers 3, 4 and 5; Build Up (D2950) on Tooth Number 4; and Root Canal (D3320) on Tooth Number 4
The insurer denied: Crown (D2740) on Tooth Numbers 3, 4 and 5; Build Up (D2950) on Tooth Number 4; and Root Canal (D3320) on Tooth Number 4
The denial is partially overturned.

The patient is an adult male requesting crowns on teeth numbers 3, 4 and 5. He is also requesting root canal treatment and core build up on tooth number 4. The prior denial was due to the teeth being considered "periodontally compromised" due to bone loss.

The crown, build up and root canal for tooth number 4 were medically necessary; however, the crowns for teeth number 3 and number 5 were not medically necessary.

Tooth number 4 has severe decay into the pulp requiring the root canal treatment, build up and crown. It only has one "4mm (millimetre)" probing depth, which is on the palatal side (out of 6 total areas 
probed). Tooth number 4 is not periodontally compromised according to the probing depths and the bone levels present on the x-rays provided. However, crowns are not needed for teeth number 3 and number 5 according to the x-rays provided. Tooth number 3 has a conservative carious lesion on the mesial side and tooth number 5 has a conservative lesion on the distal side. According to the x-rays, crowns would be overtreatment. Photos presented did not show the "severe decay" reported. Based upon the photos and x-rays, there was no need to restore teeth 3 and 5 with crowns.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension.
Treatment: Inpatient Hospital Admission.
The insurer denied coverage for Inpatient Hospital Admission.
The denial is modified. 

The patient is a female with a history of hypertension (HTN) and atrial fibrillation (AF) who presented to the Emergency Room (ER) with complaints of worsening lower extremity (LE) edema, a 1 day history of elevated blood pressure, and "feeling foggy". She recently had a baby via normal spontaneous vaginal delivery (NSVD).  The recent workup for preeclampsia was negative. The patient was admitted to labor and delivery with a diagnosis of preeclampsia.  The plan was to start a 24 hour Magnesium IV(intravenous) drip and administer IV Hydralazine as needed (PRN) for blood pressure greater than 160/110.
 
Cardiology evaluated the patient and interrogated her loop recorder.  There were no signs of arrhythmia.  A chest x-ray (CXR) came back within normal limits (WNL). Medicine consulted over the case.  A transthoracic echocardiogram (TTE) came back WNL.  Nifedipine was added to the medication regimen for blood pressure control.  Two days later, the patient reported that symptoms significantly improved. 

This patient presented 3 days weeks after delivery with elevated blood pressure. Delayed postpartum preeclampsia can be defined as signs and symptoms of the disease leading to readmission more than two days but less than six weeks after delivery.

The diagnosis of preeclampsia is based on the new onset of hypertension and either proteinuria or end-organ dysfunction after 20 weeks of gestation in a previously normotensive woman:

Systolic blood pressure >=140 mmHg(millimeters of mercury) or diastolic blood pressure >=90 mmHg, and
Proteinuria >=0.3 grams in a 24-hour urine specimen or protein: creatinine ratio >=0.3, or
Signs of end-organ dysfunction (platelet count <100,000/microliter, serum creatinine >1/1 mg/dL(Milligrams per decilitre) or doubling of the serum creatinine, elevated serum transaminases to twice normal concentration).

This patient had elevated blood pressure, no protein in the urine and no elevated liver function tests (LFTs) and no end organ dysfunction. 

This patient did not have a diagnosis of preeclampsia.  She had significant elevation in her blood pressure. There was, however, a concern about a cardiac issue, arrhythmia and cardiomyopathy.

While blood pressure control could have been managed at an observational level, there was concern about significant heart pathology so admission was medically necessary for a complete evaluation.  However, once the patient has been worked up and cleared from any cardiac pathology, she could have been discharged and followed as an outpatient for control of her blood pressure.

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

The Inpatient Hospital Admission was medically necessary.  However, ongoing admission is denied. The insurer's denial of coverage for the Inpatient Hospital Admission is modified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, pneumonia

Treatment: Personal Care Aide Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week - a total of 168 hours per week (split shift)

The insurer denied coverage for Personal Care Aide Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week - a total of 168 hours per week (split shift)

The denial is modified

 
This is an elderly patient with chronic medical problems.  She was recently hospitalized and treated for pneumonia.  She lives with her husband, who reportedly has dementia.  The insurer approved 11 personal care aide (PCA) hours/day, 6 days/week and 7.5 hours/day, 1 day/week (totaling 73.5 hours/week).  The request is for PCA 12 hours per day - 7 days per week: 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week.

 The Uniform Assessment System (UAS) was reviewed.  The patient's cognition is described as "modified independence."  She is totally dependent to maximal assistance for much of her Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping.  She requires maximal assistance for bathing, personal hygiene, dressing, bed mobility, locomotion and toilet transfer/use.  She requires extensive assistance for eating.  The patient is frequently incontinent of bladder and infrequently incontinent of bowel.  There have been no reported falls over the prior 90 days.  The patient's functional ability has reportedly declined since her recent hospitalization and treatment for pneumonia. However, the recent UAS is much the same as the prior 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).  However, based on the records reviewed, a live-in PCA would be appropriate as they are likely capable of providing for the patient's functional needs and have the ability to consistently obtain an 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 the provision of a live-in PCA Per Diem- 7 days/week- a total of 7 days/week.  

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Personal Care Aide Level 2: 12 hours per day - 7-day(s) per week; 12 hours per day - 7-day(s) per week - a total of 168 hours per week (split shift) is not substantiated. However, a live-in personal care aide (PCA) Per Diem- 7 days per week- a total of 7 days/week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnoses: suicidal ideation, history of generalized anxiety disorder, bipolar disorder, obsessive compulsive disorder and post-traumatic stress disorder

Treatment: Inpatient mental health admission, medication changes

The insurer denied coverage for inpatient mental health treatment in this hospital from 6/12/19-6/17/19. The denial was modified to approve 6/12/19-6/13/19 and deny 6/14/19-6/1719.
 
This patient was admitted to inpatient mental health treatment on 6/12/19 due to worsened depressive symptoms, suicidal ideation, and inability to care for herself.  She reportedly thoughts of not wanting to join her deceased father who committed suicide by shooting himself.  She had a serious past suicide attempt by shooting herself in the arm.  She reportedly was the victim of abuse and had post-traumatic stress disorder (PTSD) symptoms also as well as anxiety. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors report that patients with past suicide attempts are at high risk for suicide and that past suicide attempts are the most reliable predictors of suicide.  It also reports that patients with bipolar disorder, history of abuse / victimization, and substance use are at increased risk for suicide.  

Notes on 6/13/19 reported continued suicidal ideation and depression still at 5 out of 10 with poor appetite  and poor coping skills so she was still considered in need of hospital treatment then as she was still at high risk for suicide while presenting with those symptoms so she still required 24 hour hospital treatment until then.  As of 6/14/19, there were no reports of bizarre behavior, psychomotor agitation, aggression, self-injurious behavior, manic episodes, suicidal or homicidal ideation, intent, or plan. She reportedly was discharged 6/17/19
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart disease, anal cancer and dementia. 
Treatment: Customer Directed Personal Assistance Services 7 days per week live-in. 

The insurer denied coverage for Customer Directed Personal Assistance Services 7 days per week live-in. 

The denial is modified. 

This is an elderly patient with medical problems including heart disease, anal cancer and dementia. He lives with his family in a private residence. His 3 children and a friend are the paid caregivers. The insurer reduced his Customer Directed Personal Assistance Services (CDPAS) from 7 days/week (live-in) to CDPAS 56 hours/week. The request is reinstatement of the CDPAS 7 days/week (live-in). 

The Uniform Assessment System (UAS) report was reviewed. According to the report, "Member lives with his son and family in a private house." The patient's cognitive skills are described as minimally impaired. He is reportedly totally dependent to maximal assistance for much of his Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. Extensive assistance is reportedly needed for bathing, dressing, locomotion, toilet transfer/use and ambulation (uses a walker). Limited assistance is reportedly needed for personal hygiene and bed mobility. Eating requires supervision. He is reportedly frequently incontinent of bladder and infrequently incontinent of bowel. 

The patient's functional ability is much the same (if not slightly improved) when compared to the prior UAS report. The patient's medical condition, cognitive deficits and physical limitations are not at the level or unpredictable as to require the requested CDPAS 24 hours/day live-in; particularly in the context of living with family. This physician would agree that given the patient's reported general debility and cognitive deficits, he may benefit from additional safety monitoring. However, safety monitoring under personal care services (PCS) does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. Based on the records reviewed, reducing his CDPAS from 7 days/week (live-in) to CDPAS 56 hours/week is excessive. This physician recommends CDPAS 84 hours/week. The patient's functional needs are more appropriately provided and maintained with CDPAS 84 hours/week, shared household responsibility of other adults living in the home and informal care from family. 

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 Customer Directed Personal Assistance Services 7 days per week live-in from Personal Touch Home Care of NY Inc services is not substantiated. However, CDPAS 84 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right above knee amputation

Treatment: Purchase of lower limb prosthetics and accessories

The insurer denied coverage for purchase of lower limb prosthetics and accessories.

The denial is overturned.

This is a male patient with a history of right above knee amputation. The patient has been wearing a stump shrinker and has been compliant with home stretching/exercises. The patient is currently using a wheelchair for mobility. He is ready to begin training and fitting with prosthesis. Under review is the medical necessity for purchase of lower limb prosthetics and accessories.   

The preparatory prosthesis is a custom made patient-specific item (not loaned) that is utilized for the training and eventual provision of a permanent prosthesis. The initial (thermoplastic) socket will need to be replaced as the residual limb continues to heal and mature. A permanent socket is then provided. However, the initial mechanical knee and foot components can be used for the permanent prosthesis.  

From a physical medicine & rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the prosthetic components are not loaned items. The initial (thermoplastic) socket will eventually need to be replaced with a permanent socket. However, the initial mechanical knee and foot components can be used for the eventual permanent prosthesis.

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

The insurer's denial of coverage for purchase of lower limb prosthetics and accessories should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The health plan's determination is overturned in part. A 2 day stay was appropriate. 

The patient is a male with past medical history (PMH) of seizure disorder and non-compliance with AEDs (anti-epileptic drugs), hypertension (HTN), and traumatic brain injury (TBI) who was admitted with complaints of (c/o) suffering from a seizure. Vital signs were unremarkable. Physical exam was notable for no apparent distress (NAD). Lab work was notable for white blood cell count (WBC) 12.6, and a negative urine culture. A chest x-ray (CXR) showed no acute pathology, computed tomography (CT) head showed right parietal encephalomalacia, and magnetic resonance imaging (MRI) brain showed no acute changes. 

The inpatient hospital admission was medically necessary for 2 days. This patient presented with altered mental status and confusion after repeated seizures due to non-compliance with anti-seizure medications. The patient was at risk of subsequent seizures and was clearly documented to be altered on admission, which did not immediately resolve.

However, day 2, the reviewed documentation states that the patient was alert and oriented to person, place and time, that the neurological examinations were within normal limits, and there was no acute worsening during the hospital stay. There were no new focal neurologic deficits. Imaging was negative for acute injury or disease, and the patient was not comatose or in severe alteration in mental status. There was no severe dehydration, acute psychiatric illness or problem, disruptive behavior, other acute coexisting illnesses, or otherwise clinical instability. This patient was treated with AEDs and clinical observation and was monitored for repeat seizures, both of which could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left knee pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is partially overturned.

The patient is a male with left knee pain. He was diagnosed with osteoarthritis and was admitted to hospital for an elective total knee replacement. His post-operative course was complicated by continued pain and requirement of hemovac. 

The inpatient admission was medically necessary, in part.
Specifically, the inpatient admission was medically necessary until the hemovac was removed.

The records show ongoing pain that did not respond to oral medications. He was provided with Morphine on several occasions on POD (post-operative day) #1. He also was found to need a hemovac. The hemovac was not removed until POD (post-operative day) #2. A patient after arthroplasty would be at risk for hemarthrosis. The use of the hemovac indicated ongoing drainage. A person would not be discharged with the hemovac present. Monitoring of drainage would be important.

Therefore, given the above, the initial inpatient admission was medically necessary, but the patient could have been discharged two days prior.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, in part.
The records show post surgical problems of continued pain despite oral medications. The records also showed presence of hemovac until POD (post-operative day)  #2. Medical reasons were provided to substantiate the inpatient hospitalization. However, the patient could have been discharged two days prior.