Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for Hoyer lift and a full electric bed allowing for reverse Trendelenburg position. The provider reports that this patient has specific positioning needs due to her hemiparesis, immobility, and susceptibility for skin and soft tissue breakdown. Intermittent weight measurement is reasonable for monitoring her general health status. However, these measurements can be performed in the providers office or other institutional setting. There is no indication in the available records that this patient requires frequent weight measurements at home. Thus, the requested scale attachment for a Hoyer lift is not medically necessary for this patient based on the available records. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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 Decision of Health Plan

An enrollee has requested authorization and coverage for a convergent procedure. The patient remains severely symptomatic from his atrial fibrillation (AF), and his ejection fraction is compromised. He has failed two attempts at percutaneous AF ablations with rapid recurrrences, and he has most recently developed persistent AF which has increased his symptomology from the previous paroxysmal episodes. Multiple anti-arrhythmic medications have been utilized over several years with limited success and a number of intolerable side effects. The only other reasonable alternative for the patient might be atrioventricular (AV) node ablation and permanent pacemaker insertion, but given the patients young age and compromised left ventricular (LV) function, this is a less optimal treatment option at this point. As the patient has not responded to several conventional percutaneous ablation procedures or antiarrhythmics, it is now reasonable to consider more complex, invasive and advanced techniques. A convergent surgical/percutaneous hybrid ablation procedure is a very reasonable clinical option for this patient, who has not responded to multiple first line conventional therapies. There is prior published data as to the procedures efficacy in these situations, and very recently additional randomized data has been presented of the Converge trial which showed the superiority of this procedure to conventional ablation, especially when a patient has already failed conventional ablation procedures multiple times and still remains symptomatic. Therefore, the requested convergent procedure is likely to be more beneficial than any available standard treatment for the patients medical condition.Final Result: The reviewers determined that the requested services are likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine, with subspecialty certification in cardiovascular disease. Physician reviewer 3 is board certified in internal medicine, with subspecialty certification in cardiovascular disease and clinical cardiac electrophysiology. All three physician reviewers 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 Decision of Health Plan

The enrollee is requesting authorization and coverage for Synvisc-One injection in the left knee. The patients pertinent diagnoses are degenerative joint disease of the knee, synovitis, meniscus tear, primary osteoarthritis of the left knee, and chondromalacia. The patient has been treated in the past with rest, several non-steroidal anti-inflammatory drugs, cortisone injections, braces, physical therapy and lifestyle changes; with minimal improvements in the underlying degenerative joint disease. With established efficacy of hyaluronic acid injections, and failure of other conservative treatments, including oral medication and corticosteroid injections, a repeated Synvisc-One injection is appropriate and medically necessary for this patients degenerative joint disease of the knee.  Literature reports intraarticular hyaluronic acid improved pain in five studies, or function in four studies, when compared to placebo. In sum, there is support in the literature for the use of a repeat injection for the treatment of this patients condition.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 30 Xanax 0.5 mg, to be filled every 90 days. Per the medical evidence, the use of benzodiazepines beyond short-term use (less than two to four weeks) is not indicated. This patient appears to have a medication regimen concerning for polypharmacy, which invariably compounds the risk for oversedation, given that she is on a number of sedating medications. Primary treatments for anxiety are cognitive behavioral therapy, selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. If benzodiazepines are to be prescribed on an as-needed basis, a longer acting benzodiazepine is indicated and should be prescribed sparingly. There are concerns that the requested medication may exacerbate anxiety, given its short half-life. The withdrawal symptoms from alprazolam may contribute towards panic symptoms as well as insomnia, and there are also concerns for physical dependence. Therefore, 30 Xanax 0.5 mg, to be filled every 90 days 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 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 Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for the Nutropin AQ Nuspin. He was born at 36 gestational weeks and his birth weight was 1880 grams (gm). The cut off for SGA at 36 weeks is 1889gm/43.8 centimeters per year. There was no catch-up growth since birth. He was started on growth hormone (GH) therapy in January 2020. His pretreatment height velocity is reported to have been 7 centimeters per year. His height velocity on GH therapy is reported to be 10 centimeters per year. GH for the treatment of children who are SGA and who fail to exhibit catch-up growth is the standard of care. This indication has approval from the FDA, support from consensus guidelines, and randomized controlled trial evidence to support its use. The patient appears to have failed to catch-up with a height more than 2 SDS below the mean. GH therapy for this patient is consistent with accepted standards of medical practice. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in endocrinology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for cognitive behavioral therapy (CBT) services for 45 minutes once weekly. Based on the available documentation, CBT therapy is appropriate to treat this patients presenting concerns. However, the provision of these services with an independent provider are at the patients convenience, which does not meet medical necessity criteria. Current evidence-based criteria and meta-analyses of CBT support services with a provider within the Health Plans network. The provider has not offered any information that highlights how the independent providers services are different from other providers trained in CBT. Researchers noted that CBT is a broad service delivery modality that is widely used to treat many disorders. Researchers also reported that CBT is one of the most effective treatments identified for the treatment of anxiety, depression, schizophrenia, and bipolar disorder. Given this information, the patient should receive CBT therapy with a provider within the Health Plans network. Therefore, the requested CBT services for 45 minutes once weekly are not medically necessary for 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for anterior cervical discectomy with fusion sooner than presently scheduled by the provider (2+ months). In this case, the patient presents with complaints of worsening neck pain radiating into the bilateral upper extremities. The patients reported signs and symptoms are consistent with possible cervical myelopathy and correlate with imaging findings of C5/6 disc and osteophyte complex protrusions indenting the spinal cord with possible cord signal change. The patient has reportedly failed conservative treatment, and he has been recommended for C5/6 anterior cervical discectomy and fusion, which is apparently scheduled for a date that is 2+ months distant. He is requesting an earlier surgical date. Records document that he has been placed on the surgical scheduling list as a high priority. However, surgeries were being scheduled based on medical necessity and pandemic reopening guidelines. Records reflect that the patient has been advised to present to the emergency department for any new or worsening neurologic symptoms. There is no indication that the patient has emergent indications at this time to support an earlier surgical date. Under these circumstances, a surgical date for an anterior cervical discectomy with fusion earlier than presently scheduled is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that requested scheduling of services is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for platelet-rich plasma (PRP) epidural injections for the cervical spine and thoracic spine. The American Society of Interventional Pain Physicians (ASIPP) guidelines state that based on best evidence synthesis principles based on a single systematic review, and five individual studies, the evidence for management of low back and lower extremity pain with epidural biologic injections has been assessed as level four out of five for PRP. The ASIPP concluded that the available studies provide limited evidence for PRP injection therapy in the management of discogenic pain. In this case, the patient has signs and symptoms suggestive of cervical radiculopathy. The records document that he has failed several conservative therapies including non-steroidal anti-inflammatory drugs (NSAIDs), a transcutaneous electrical nerve stimulation (TENS) unit, stretching, and opioid therapy. Following thorough evaluation and examination, the patients providers have recommended cervical fusion and epidural steroid injections. The patient has declined these options and is requesting PRP epidural injections. Overall, the current evidence for PRP injections for back and extremity pain is weak. There are insufficient high quality demonstrating that PRP is effective for treating cervical radiculopathy or thoracic spine pain. Based on the available medical records, the requested PRP epidural injections for the cervical spine and thoracic spine are not medically necessary for 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 anesthesiology with subspecialty certification in pain management 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 Decision of Health Plan

An enrollee has requested authorization and coverage for mastectomy, simple, complete, biopsy or excision of lymph node(s), open, deep axillary node(s), injection procedure, radioactive tracer for identification of sentinel node, and lymphatics and lymph nodes imaging. Based on the patients family history, workup, and genetic counseling, she is thought to have an increased risk of breast cancer. The patient has requested prophylactic bilateral simple mastectomy and lymph node sampling in order to reduce her risk for breast cancer. However, prophylactic bilateral mastectomy with lymph node sampling for risk reduction of breast cancer risk has only been demonstrated to be effective and medically necessary for individuals with documented inherited germline mutations (NCCN Guidelines for Genetic/Familial High-Risk Assessment: Breast, Ovarian, Pancreatic). The most well documented germline mutation of BRCA 1/2 that supports prophylactic surgery is wild-type for the patient and therefore not medically necessary for this patient. In addition to continued updated multi-panel germ-line testing, the patient has a number of dietary/lifestyle/and chemoprevention interventions that are available to her for risk reduction (NCCN Guidelines for Breast Cancer Risk Reduction). Under these circumstances, the requested mastectomy, simple, complete, biopsy or excision of lymph node(s), open, deep axillary node(s), injection procedure, radioactive tracer for identification of sentinel node, and lymphatics and lymph nodes imaging are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty 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 Decision of Health Plan

The patient has requested authorization and coverage for bilateral turbinate reduction, septoplasty, nasal vestibular body reduction, and bilateral Latera implants. The submitted documentation supports the medical necessity of a portion of the requested services. This patient has a history of nasal obstruction. The records indicate that the turbinates are the largest contributor to his nasal obstruction. He also had septal spurs bilaterally that impede the nasal airway. Septoplasty and turbinate reduction are likely to improve the patients nasal airway. Although a nasal decongestant may provide temporary relief, a permanent improvement can be obtained with turbinate reduction surgery. In this patients case, the requested septoplasty and turbinate reduction are medically necessary. The records fail to demonstrate the medical necessity of the requested nasal vestibular body reduction and bilateral Latera implants. The Latera implant and vestibular body reduction may be indicated if lateral wall stenosis or collapse is the major issue. In this case, a Cottle maneuver was not performed to show that the lateral nasal wall was a major contributor to the nasal obstruction. Therefore, the requested bilateral turbinate reduction and septoplasty are medically necessary for the treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in otolaryngology 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 Decision of Health Plan

Nature of Statutory Criteria/ Case Summary: The patient has a ten-year history of migraines, chronic cluster headaches, and occipital neuralgia. At issue is whether the requested medication, Emgality, is medically necessary to treat the enrollees medical condition. He presented for the evaluation of severe head pain. The patient's migraine disability assessment score (MIDAS) was at 90 indicating a severe disability. The patient was started on Emgality and was taking sumatriptan 12 times daily. The patient reported a 56% reduction in the number of episodic cluster headaches and is free of headaches for 3-4 days per week. The patient has previously tried and failed all first-line therapies for cluster headaches including lithium, anticonvulsants, and glucocorticoids. There are no other therapies that are as likely to be as effective as Emgality. The patient has tried and failed more than 30 therapies for prevention of migraine. Emgality is approved by the FDA and literature supported for cluster headaches. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in neurology        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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for any or all facial feminization services: grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet, 25 cc or less injectate; grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet, each additional 25 cc injectate, or part thereof; genioplasty augmentation; tracheoplasty cervical; otoplasty protruding ear, cervicoplasty; excision excessive skin and subcutaneous tissue other area; reduction forehead contouring only; osteoplasty facial bones reduction. Researchers reported that transwomen have diminished mental health-related quality of life compared with the general female population. However, surgical treatments (e.g. facial feminization surgery, gender reassignment surgery, or both) are associated with improved mental health-related quality of life. The World Professional Association for Transgender Health (WPATH) position statement notes, Non-genital surgical procedures are routinely performed notably, subcutaneous mastectomy in female-to-male transsexuals, and facial feminization surgery, and/or breast augmentation in male-to-female transsexuals. These surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals. The Health Plans claim that the patients individual facial features fall within a normal range for a female does not address the masculine impression of the facial features in relation to one another, nor the resulting dysphoria the patient experiences. The medical evidence supports the requested surgeries in this clinical setting. Therefore, all of the following requested facial feminization surgeries are medically necessary for the treatment of this patient: grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet, 25 cc or less injectate; grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet, each additional 25 cc injectate, or part thereof; genioplasty augmentation; tracheoplasty cervical; otoplasty protruding ear, cervicoplasty; excision excessive skin and subcutaneous tissue other area; reduction forehead contouring only; osteoplasty facial bones reduction. Final Result: The reviewer determined that all 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 with expertise in transgender health 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.