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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for buprenorphine for treatment of the enrollee, who has a history of lower back pain. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity of the requested buprenorphine in this clinical setting. The records do not mention counseling, despite research and recommendations to support its use in opioid dependency and abuse. Moreover, the notes state he is taking methadone, Percocet, and buprenorphine. There is no clear objective functional goals for the additional buprenorphine being requested. Buprenorphine is only U.S. Food and Drug administration approved and indicated for opioid dependence. However, it is unclear why Suboxone is not sufficient for this patient, given the history, per the provider, of abusing opioids. Per the records, this patient has been on Suboxone for one month. Further, this patient does not acknowledge he has an opioid dependency. The patient does not state he is taking the medication to be free from opioids but rather he is requesting the medication for pain control. Finally, multiple minimal requirements for opioid prescribing have not been performed and the need to use buprenorphine, alongside, other possible opioids for an indefinite basis, as the primary medication treatment strategy for pain or opioid dependency have not been established. 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 anesthesiology with sub-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: Overturned

A 37-year-old female enrollee has requested adjuvant Goserelin therapy for treatment ofher Stage IIIA infiltrating ductal carcinoma of the right breast.  Findings:  Three physician reviewers found that women with hormone receptor positive breast cancer usually receive some pharmacologic therapy to inhibit the estrogen induced growth of the cancer. The interventions differ however for those who are premenopausal versus postmenopausal.  The Early Breast Cancer Trialists Collaborative Group (EBCTCG) published an overview and meta-analysis which showed a significant survival benefit for those women treated with ovarian ablation or suppression. There is a large study published in 2009 which showed that adjuvant goserelin was as effective as tamoxifen.  In those women not treated with tamoxifen, significant benefit of goserelin was seen for survival and recurrence rate. The National Cancer Institutes Physicians Data Query lists both options (tamoxifen or ovarian ablation/suppression) for premenopausal women with node positive disease. All told, there is sufficient scientific evidence demonstrating that this patient should continue with and complete her five years of adjuvant goserelin/letrozole therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment program services for treatment of his behavioral health condition.  Findings: The physician reviewer found that residential treatment program services are medically necessary for treatment of the patients medical condition. Based on the documentation provided, the patients mental illness causes significant impairment across multiple functional domains. The adequately dosed evidence-based pharmacotherapy, in conjunction with weekly psychotherapy facilitated by specialty provider, appears to be inadequate as the patient has been unable to generate any meaningful therapeutic progress or consolidate the foundation necessary for recovery. Further, the treatment team who knows this patient best has recommended a residential placement. In sum, the proposed treatment would reasonably be expected to improve the patients condition and prevent a more serious episode of illness.  Further, residential placement would be considered safe, appropriate and consistent with good practice. Considering the clinical presentation and perusal of the peer-reviewed literature, residential treatment program services are medically necessary for treatment of the patients behavioral health condition.  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 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: Upheld

A 32-year-old female enrollee requested authorization and coverage of uterine artery embolization. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees uterine fibroids.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is an eight-year-old female with an inoperable brain tumor who is status post ventriculoperitoneal shunt implantation. The patients parent has requested authorization and coverage for a referral to a pediatric neurosurgery capable facility for a monitoring MRI. The Health Plan has denied her request on the basis that the requested referral is not medically necessary.There is no medical indication for the patients monitoring MRI to be performed at a facility with an on-site pediatric neurosurgeon. Medically reasonable and appropriate services have been authorized by the Health Plan. There is no evidence to suggest the presence of a neurosurgeon at the MRI facility is medically warranted. Therefore, I have determined that the requested referral is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a two-year-old female enrollee has requested for Synagis vaccination for treatment of the enrollees cyanotic hypoplastic heart.    Findings:  Two physician reviewers found that Synagis has been available for prevention or amelioration of the effects of RSV for the past decade. Its ultimate value remains under study, but it is in widespread use throughout the United States. Synagis is presently considered the standard of care as outlined in the 2008-2009 Guideline for use from the Division of Infectious Diseases of the Department of Pediatrics at the S.U.N.Y. at Syracuse (cited above). These guidelines are the same as those published by the American Academy of Pediatrics in 2003. In relevant part, a portion of the Guidelines read as follows: RSV prophylaxis is recommended for infants who are 24 months of age or younger with hemodynamically significant congenital heart disease. It is estimated that by 2 years of age nearly all children have been exposed to, and test positive for, RSV. Neither the safety nor efficacy of Synagis beyond the age of 2 years has been demonstrated by research. While there may be potential for benefit, at this point in time there is no confirmatory evidence to support the use of Synagis in patients older than 2 years even in the presence of significant congenital heart disease.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospitalization services. Findings:  The physician reviewer found that Spinal cord compression, which often presents with a combination of symptoms that can include motor weakness and sensory changes, is generally considered a neurosurgical emergency and delays in the diagnosis and treatment can result in progression of neurological dysfunction.  O'Phelan notes that as interventions are critically time-sensitive, the recognition and treatment of spinal cord compression is part of emergency neurologic life support protocol. Cram and colleagues report that there is variation in the utilization of cervical spine surgery. In this case, the patient was admitted for hospitalization on the recommendation of the treating provider upon presenting to the emergency department. The records documented the providers recommendation for  decompressive surgery upon the patients admission for treatment of severe cord compression causing documented neurological symptoms. The patients condition eventually improved with intravenous steroids, a treatment that could only have been administered in the hospital setting and based on the improvement in her clinical condition, the patient was discharged home with plans for further conservative therapy and consideration for outpatient surgery down the road. In this case, given that the records document that the assessment of the providers upon the patients admission that the severity of her condition required urgent surgery, the services at issue were medically indicated. Therefore, inpatient hospitalization services were medically necessary for the 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 neurological 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: Upheld

A 48-year-old female enrollee has requested an MRI of the right knee for evaluation of her knee pain. Findings:  The physician reviewer found that the indications for MRI of the knee have broadened over time. Initial indications for the test were to avoid unnecessary arthroscopic evaluation (Southgate and Thomas) and the avoidance of unneeded specialist evaluations (Solomon). However, the utilization of the MRI for the diagnosis of internal derangements of the knee, as opposed to clinical evaluation, has led to an increased dependence on this test, rather than the equally accurate evaluation by a skilled orthopedic surgeon (Kocabey). In this patients case, another orthopedic consultation has been authorized by the Health Plan. This consultation is an appropriate next step in this setting and is indicated prior to consideration of an MRI. At this time, there is no evidence that an MRI is medically necessary to evaluate this patients condition, thus the Health Plans denial was appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer. Two physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of very dense breast tissue where the utility of standard digital mammography alone is limited. All told, the use of digital breast tomosynthesis in this patient was likely to have been more beneficial than standard screening mammography alone.  Final Result: Two 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: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three 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

The patient is a 27-year-old female who underwent bilateral functional endoscopic sinus surgery, inferior turbinate reduction and septoplasty in March of 2000 to treat symptoms including nasal airway obstruction and nighttime headaches that were unresponsive to medical therapy. The operative report from that surgery indicates that pre-operatively there was a sharp rightward deviation of the nasal septum. This was repaired by separating the septum from the maxillary crest, taking the crest down and moving the septum to the right, supposedly to midline. The patient did well postoperatively for a few months, but then had recurrence of her original symptoms. She states that my septum leaned to one side and could be pressed flat with little effort on the top of my nose.  The patient sought further care in December of 2005 based on her continued nasal airway restriction. She was found at that time to have a leftward septal deviation, partial turbinate reduction, a dorsal hump and loss of tip support. In January 2006 she underwent septorhinoplasty with an ear cartilage graft placed for tip support and infracture of the turbinates. The operative report is sparse, but it appears osteotomies were done and the dorsal hump and the widened tip were addressed. The patient relates her symptoms have improved after this surgery. The Health Plan denied the patients request for reimbursement indicating the nasal surgical procedures were not medically necessary.The patient underwent revisional nasal surgery with the intent of correcting her continued nasal airway restriction. This was accomplished to her satisfaction and a portion of the surgery would be considered a functional correction. This would include the revisional turbinate reduction (CPT Code 30130), the septoplasty portion of the septorhinoplasty (not previously billed separately; included in CPT Code 30420) and the anesthesia procedure (CPT Code 01999). However, the portions of the surgery where the surgeon uprighted the pyramid and smoothed the top and trimmed the alar cartilages but very conservatively to take care of her widened tip were not medically necessary and the grafting (CPT Code 21235) and septorhinoplasty (CPT Code 30420) were cosmetic procedures.Based upon the information set forth above, I have determined that a portion of the procedures at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested a PET scan for evaluation of  her gastric lymphoma. Findings:  Two physician reviewers found that the current medical evidence does not support the requested PET scan in this clinical setting.  The National Comprehensive Cancer Network guidelines call for regular clinical follow-up every three to six months for five years, then yearly (or as clinically indicated) follow-up thereafter.  There is no mention made of obtaining regular PET scans in patients who are felt to be in complete remission. Minimal adequate radiological examinations by CT scan at 6, 12, and 24 months after end of treatment are indicated. The authors noted that routine surveillance with PET scan is not recommended (Tilly and colleagues).   Furthermore, there is a lack of data indicating that slightly earlier detection of recurrent lymphoma before the disease becomes clinically manifest will result in any improvement in outcome.  The majority of relapses occur during the first two years after finishing treatment.  Relapses usually cause the person to have symptoms and are rarely found solely on the basis of routine radiologic imaging tests.  Furthermore, PET scans run the risk of revealing false positive results.  All told, in this patients case, the requested PET scan is not likely to be superior over other methods of evaluation.
Appeal type: Experimental/Investigational
Decision: Overturned

A 45-year-old male enrollee requested the LINX procedure for medical treatment of his gastroesophageal reflux disease (GERD).   Findings:  Two physician reviewers found that the patient has documented acid reflux which has been confirmed by endoscopy and pH studies. He has bolus regurgitation. Consistent with the available peer-reviewed medical literature, this patient is an ideal candidate for the LINX procedure. Further, the potential morbidity from a Nissen fundoplication can be avoided. The long-term data is accumulating and in properly selected patients LINX has been shown to be a durable procedure. Therefore, the requested LINX procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment center (RTC) services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that In cases such as this, an evidence based instrument such as the Child and Adolescent Level of Care Utilization System (CALOCUS) is indispensable in determining necessary level of care for children, to insure their level of care meets their individual needs at the least restrictive setting possible. Based on this patients presentation, she is at some risk of harm (score 2) due to the patients history of impulsive actions and aggression.   However, the medical records indicate that the patient was not actively suicidal. The patient has moderate problems with her functional status (score 3) given school disruption. The patient has mild co-morbidities (score 2) as she does not have active serious medical problems but has substance use history. The patients recovery environment is mildly stressful (score 2) with a stable housing situation despite strained relationships with her mother. The patients recovery environment is supportive (score 2) as the patients father is involved in treatment and is supportive. The patient has demonstrated moderate response in previous treatment (score 3) and has been constructive in treatment (score 2) as she participates in therapy and has used coping skills learned in therapy per the records. The patients parents work actively and constructively with providers (score 2). These findings given the patients presentation a composite score of 18 which correlates with IOP level of care. According to the CALOCUS the patient would need to have a score of 23-28 in order to require treatment in an RTC. Thus, the patient can be treated in a less restrictive setting safely and effectively and the requested RTC services are not supported as medically necessary for treatment of this patients behavioral health issues. 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 psychiatry with sub-specialty 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: Upheld

A 52-year-old female enrollee has requested Botox injections for treatment of her chronic tension headaches.  Findings:  Two physician reviewers found that this patient carries a diagnosis of chronic tension headaches. Tension headache is by definition mild to moderate, and thus, with stated periodically severe headaches, the diagnosis appears uncertain. The published medical literature supports the use of Botox for preventive management of chronic migraine, as does the FDA indication, with approved dose of 155 Units. A study by Silberstein of Botox for chronic tension headache concluded that, The literature does not indicate that Botox is beneficial for management of tension type headache, either episodic or chronic. Therefore, this patient should be referred to consult with a headache specialist to identify the correct diagnosis and to direct treatment accordingly. However, given the description and frequency of this patients condition, the requested Botox therapy is not likely to produce an improved health outcome when compared with standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee requested authorization and coverage of an MRI of her lumbar spine and an MRI of her cervical spine. The Health Plan denied the request indicating that the requested MRIs are not medically necessary for evaluation of the enrollees pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer partially overturned the Health Plans denial on the basis that the requested MRI of the lumbar spine is medically necessary, but that the requested MRI of the cervical spine is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tibsovo (ivosidenib) 500 mg once daily. In the medical literature, Researchers reported on an open-label, phase I, dose escalation and expansion study of Tibsovo in patients with solid tumors with IDH1 mutations. The authors found that Tibsovo dosed at 500 mg once per day in 66 patients was associated with a favorable safety profile, which is promising. However, there is a paucity of prospective large controlled trials and major compendia supporting an indication for Tibsovo in the treatment of oligodendroglioma. In addition, the U.S. Food and Drug Administration (FDA) has not approved Tibsovo for the treatment of oligodendroglioma. Currently, there is greater evidence for a dual mutant-IDH1/2 inhibitor, vorasidenib, which has entered phase III testing in patients with grade II non-enhancing IDH-mutant glioma. Moreover, the patients records do not report that he has failed treatment with standard therapeutic regimens such as procarbazine, lomustine, and vincristine (PCV), and temozolomide. Given these findings, the requested Tibsovo (ivosidenib) 500 mg once daily is not medically necessary for 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 subspecialty certifications in medical oncology and hematology 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.