Persius/imr-appeals huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested the prescription medication Provigil for treatment of her depression. Findings:  The physician reviewer found that the submitted clinical information does not demonstrate Provigil is medically indicated for this patient. There are many other treatment options available for treatment of her depression prior to augmentation of an anti-depressant with a psycho-stimulant. Provigil is still considered investigational for the treatment of depression as there are concerns about its safety and side effects, particularly for someone with a chronic condition such as Crohns disease.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested Subutex (buprenorphine) for treatment of her lumbar pain and leg pain.  Findings:  The physician reviewer found that Baron and Mao reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a pre-existing pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Consistent with these findings, it was in the patients best interest to wean down or off all opiates prior to surgery as this could reduce her incidence of opioid-induced hyperalgesia. Rozen and colleagues reported that opioid agonist-antagonist have been approved for opioid addiction but that providers are often hesitant to prescribe agonist-antagonist and partial agonist to opioid tolerant patients, fearing that these drugs may precipitate withdrawal. All told, the Subutex provided to this patient was not medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The father of a nine-year-old male enrollee requested authorization and coverage of an adult tricycle. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees Duchenne muscular dystrophy.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for applied behavior analysis (ABA) therapy using Early Start Denver Model (ESDM). ABA continues to be the most evidence-based intervention to treat the symptoms of autism. While many early intensive behavior intervention models incorporate ABA, ESDM utilizes ABA loosely among other eclectic approaches from teaching and psychology. Evidence on the effectiveness of ESDM is limited, as much of the research regarding its effectiveness has come from its developers. Further, much of the research that has been published has been identified to be weak in scientific rigor. There where 15 studies that evaluated ESDM as an early intervention program for a total of 209 children with autism spectrum disorder. The authors noted that although ESDM is a potentially promising intervention, the limited number of high-quality studies indicates the need for additional research to evaluate its effectiveness. At this time, there is insufficient data to draw firm conclusions about its use. The Health Plan has offered coverage for ABA therapy with an in-network provider, which is medically appropriate in this case. Therefore, ABA therapy using ESDM is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in a licensed B.C.B.A., board certified in psychology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the intravitreal corticosteroid implant performed. Findings: The physician reviewer found that the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient presented with unilateral painless loss of vision associated with optic nerve swelling and inferior altitudinal defect. There was no enhancement of the optic nerve on MRI. In addition, the patient appeared to have a contralateral crowded disc with 0.1 cup to disc ratio. Moreover, there is a lack of documentation demonstrating that the optic nerve swelling was related to posterior uveitis instead of ischemia. Given the lack of clinical indication of an inflammatory etiology for the optic nerve swelling, the Ozurdex injection would not be clinically indicated. All told, the intravitreal corticosteroid implant performed on the date of dispute was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers 2/3 determined that the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in ophthalmology and are actively practicing. The reviewers  are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral Euflexxa injections. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior Euflexxa injections to the bilateral knees with the relief lasting six months each time. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, bilateral Euflexxa injections are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. This gives the patient a composite score which is consistent with medically monitored community based services. However, due to the patients scores on risk of harm, the recommended level of care is Level 5 medically monitored residence based services. Thus, the RTC services provided were medically necessary for this patient. Given these findings, the RTC services provided, and 90 days of psychiatric RTC services, were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed .Findings:  The physician reviewer found that Tomosynthesis is rapidly becoming a standard problem-solving tool in evaluating dense breasts or suspicious calcifications. In this case, the patient has breasts that have been described as very dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Accordingly, the digital breast tomosynthesis performed on the date of dispute has been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer number 1,2 & 3 are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cervical interlaminar epidural steroid injection at level C6-7. The updated American Society of Interventional Pain Physicians (ASIPP) guidelines state that the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness. The ASIPP guidelines also state that there is level 2 grade medical evidence to support use of these injections for patients with cervical stenosis conditions. In this case, the patient has cervical radiculopathy confirmed by physical examination and EMG study. In addition, the patients CT scan of the neck confirmed corresponding degenerative spine changes associated with neuroforaminal stenosis. The patients condition has not responded to three months of conservative care including medication management with NSAIDs, opiates, and neuromodulating agents. Moreover, the patient has been treated with a course of physical therapy and a home exercise program without adequate benefit. The next step in the treatment algorithm involves an epidural steroid injection. There is Level 1 and 2 evidence in the peer-reviewed medical literature demonstrating that this treatment can be effective for treatment of this patients cervical radiculopathy and stenosis. Given these findings, the requested cervical interlaminar epidural steroid injection at level C6-7 is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test (fetal sex and/or fetal chromosomal microdeletion(s) genomic sequence analysis, circulating cell-free fetal DNA in maternal blood).Findings:  Two of the three physician reviewers found that the American College of Obstetricians and Gynecologists recommends cell-free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population was defined as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first-trimester or second-trimester screening test results. Since this patient is 27 years old, the aneuploidy risk for this patient in this pregnancy does not warrant cell-free DNA testing for aneuploidy. Testing for sex chromosomes and microdeletion syndromes is also not indicated. Given the rarity of these conditions, the detection rate is significantly lower than for trisomy 21 and 18. In sum, the superior efficacy of gene test (fetal sex and/or fetal chromosomal microdeletion(s) genomic sequence analysis, circulating cell-free fetal DNA in maternal blood) has not been established.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewer 1 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 2 is board certified in clinical cytogenetics and genomics and is actively practicing. Physician reviewer 3 is board certified in clinical biochemical genomics and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee requested Soma three times per day for treatment of her chronic pain.   Findings:  The physician reviewer found that the current standard of care for chronic pain and spasms is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Soma is a muscle relaxant with more addictive and abusive properties than opioids. Additionally, Soma is a centrally acting muscle relaxant, associated with a high risk of dependence and tolerance. The aim of current guidelines is to protect patients from the adverse effects of medication therapy.  Soma as requested by the patient would be contradictory to providing safe and effective healthcare. For these reasons, the requested Soma three times per day is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The Mother of an 8-year-old male enrollee requested authorization and coverage of home oxygen. The Health Plan denied the request indicating that home oxygen is not medically necessary for treatment of the enrollees cyanosis during seizures.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a three-year-old male enrollee has requested speech therapy for treatment of the enrollees articulation disorder. Findings:  The physician reviewer found that this patients developmental history included some slight delays, as he was not sitting until age 12 months and was not walking until age 24 months. The remainder of his development has been normal. There is no documentation suggesting that the patient did not catch up from a gross motor and fine motor standpoint of his delays.  There is a lack of recent studies showing the benefit of speech therapy for articulation disorders at this age. Additionally, based upon the norms for the development of language and articulation, the delays noted in the submitted documentation are within functional limits for his age. In this patients case, speech therapy is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for psychiatric intensive outpatient program (IOP) services (24 sessions). The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The composite score is then used to determine the level of care needed. Applying the LOCUS guidelines, this patient met the criteria for IOP level of care services. The patient was at moderate risk of harm (score 3) due to chronic suicidal ideation and a recent suicide attempt two days prior to IOP admission. The patient demonstrated moderate functional impairment (score 3) given his inability to perform activities of daily living, difficulty sleeping, and inability to maintain intake. The patient has no significant comorbidities (score 1) per the records. The patients recovery environment was moderately stressful (score 3) as he was recently divorced and lives in the same home as his ex-wife. The patient identified that the holidays are major trigger for him. The patients recovery environment provided limited support (score 2) due to his social isolation and strained relationship with his ex-wife. The patient has exhibited poor response to prior treatment (score 4) as he failed prior IOP one month prior to readmission, as well as outpatient treatment, which recently consisted of daily services. The patient was constructive in treatment (score 2). The provider noted that the patient was adherent with his care and compliant with his medications. This gives the patient a composite score of 18, which is consistent with high intensity community based services, such as IOP. Given this support, the psychiatric IOP level of care services (24 sessions) were medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 66-year-old female enrollee has requested a robotic-assisted sacral colpopexy for treatment of her vaginal prolapse.  Findings:  The physician reviewer found that the current medical evidence supports the requested procedure in this patients case.  As noted by Di Marco and colleagues, robotic-assisted laparoscopic sacral colpopexy may provide the same long-term durability of open sacral colpopexy with the benefit of a minimally invasive approach.  Elliott and colleagues noted decreased hospital stay, low complication rates and high patient satisfaction with a minimum of one-year follow-up for patients following robotic-assisted laparoscopic sacral colpopexy. Gilleran and colleagues noted that the primary advantages for robotic-assisted sacral colpopexy include decreased blood loss and shorter hospital stay.  Overall, the medical literature supports the use of robotic-assisted sacral colpopexy in this clinical situation. In experienced hands, the robotic approach has less blood loss, shorter hospital stays, and quicker recovery than traditional open or vaginal approaches.  All told, the requested robotic-assisted sacral colpopexy is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tibsovo 250 mg two (2) tablets daily. The U.S. Food and Drug Administration indicates that Tibsovo, an isocitrate dehydrogenase-1 (IDH1) inhibitor, is appropriate for the treatment of advanced acute myeloid leukemia. While researchersfound that ivosidenib was well-tolerated with no dose-limiting toxicities in a phase I trial of 66 patients with advanced IDH1-mutant astrocytoma, oligodendroglioma, or glioblastoma, the National Comprehensive Cancer Network recommends several other treatment options. In this case, the patient has only been treated with surgery, and the documentation does not reflect other attempted therapies or treatment options, including possible resection, radiation, temozolomide, Lomustine or carmustine, and platinum-based regimens. Given the patients diagnosis and other available treatment options, the use of ivosidenib is not medically indicated. Therefore, Tibsovo 250 mg two (2) tablets daily are  not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old male enrollee has requested for a new prosthesis for treatment of his left leg below the knee amputation. Findings:  The physician reviewer found that , it is clear that this patient requires replacement of the left lower limb prosthesis. He has lost at least 17 pounds, and this would definitely cause poor fit of the prosthetic socket. This patients prosthetic foot/ankle component is worn out.