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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the computed tomography (CT) scan provided on 9/12/17 for evaluation of the enrollees back pain. Findings:  The physician reviewer found that This patient had symptoms which were suspicious of a compression fracture in the mid thoracic spine, possibly on the basis of insufficiency. There were positive radiographic findings on plain film imaging. Given these findings and the clinical symptomatology, further evaluation by computed tomography (CT) was indicated in order to assess the nature of the possible compression fracture and if present, whether the fracture involved the posterior column of the spine, which would have revealed an unstable fracture. Such determinations are not possible on plain x-rays and cross-sectional imaging. For these reason, in this case, the CT scan provided was medically necessary for further evaluation of this patients medical condition. Final Result: The reviewer determined that the diagnostic procedure at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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: An enrollee has requested authorization and coverage for Supartz injections in both knees. Findings:  The physician reviewer found that evidence based medical peer reviewed literature supports the use of repeat viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Studies concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Studies conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Studies concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow up period. The medical literature and evidence support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. The literature also states that if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. High quality scientific evidence does not appear to place a maximum amount of injections that an individual may receive for treatment of osteoarthritis of the knee. Moreover, viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement. In this case, the patient has been diagnosed with bone on bone arthritis of both knees. He has significant bilateral knee pain and functional impairment in mobility that have failed to respond adequately to other conservative treatment, including activity modification, corticosteroid injection, and medications. The patient reported benefit with prior viscosupplementation lasting for at least six months. Therefore, Supartz injections in both knees is medically necessary for treatment of the patients medical 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 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 Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Monovisc injection to the right knee for treatment of the enrollees knee pain. Findings: The physician reviewer found there is sufficient support for the requested services in this clinical setting. This patient presents with chronic right knee pain with associated stiffness, swelling and weakness. Functional limitations were documented with stairs and prolonged sitting. Clinical examination findings were consistent with the diagnosis of medial compartment osteoarthritis. He has not obtained significant symptom relief with prior conservative treatment, including medications, activity modification, and physical therapy. The records noted that prior viscosupplementation injections had provided significant sustained relief. It was also noted that he was attempting to delay knee replacement surgery given his young age. The peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Therefore, the requested Monovisc injection to the right knee is 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 Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha 140 mg/ml SureClick injections for treatment of the enrollees hyperlipidemia. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. This patient has documented coronary and vascular disease as well as hyperlipidemia. The records document intolerance to several statin medications and Zetia. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 1 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter criteria. In this setting, PCSK9 inhibitors have been demonstrated to be effective at lowering cholesterol and are associated with improved cardiovascular outcomes. Thus, Repatha 140 mg/ml SureClick injections are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is 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 internal medicine with sub-specialty certification in cardiovascular disease 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Serostim for treatment of the enrollee who has a history of human immunodeficiency virus. Findings:  The physician reviewer found that There is a lack of support for the requested medication in this clinical setting. The current guidelines do not provide specific recommendations for the medication Serostim in treatment of HIV patients who may be experiencing unintentional weight loss. The U.S. Food and Drug Administration approved this medication for the treatment of HIV patients with wasting or cachexia to increase lean body mass and body weight, and improve physical endurance. Concomitant antiretroviral therapy is necessary. In this patients case, depending on the formula used, this patients ideal body weight would be between 152 to 159 pounds. The patients weight was 160 pounds. There is no documentation of recent weight loss.  As such, the Health Plans denial is consistent with best community practice. The requested therapy with Serostim is not indicated based on the available FDA criteria and the patients medical records provided for review. For these reasons, Serostim is not medically necessary for the treatment of this patient. Final Result: The reviewer determined 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 infectious disease 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for armodafinil (Nuvigil) for treatment of the enrollees idiopathic hypersomnia. Findings:  The physician reviewer found that current diagnostic criteria for idiopathic hypersomnia require an exclusion of other causes of daytime sleepiness and objective findings on testing to establish the diagnosis. In this case, the patient does not meet the diagnostic criteria based on the information provided for review. The patient did not undergo a multiple sleep latency test (MSLT) and the PSG suggested possible insufficient sleep time. In addition, the patient has another potential cause of sleepiness which is post-stroke fatigue. Post-stroke fatigue is a common finding in patients who have sustained a stroke. Studies have been taken to evaluate the use of pharmacotherapy in post-stroke fatigue. However, there is no conclusive evidence supporting the efficacy of pharmacotherapy. Currently, further study of pharmacotherapy for this condition is needed. Nuvigil has not been studied directly for post-stroke fatigue. Nuvigil is the R-enantiomer of modafinil which is a racemic mixture and a recent phase 3 study on modafinil failed to show any benefit when compared to placebo. In this case, the diagnosis of idiopathic hypersomnia is not supported by the records and there is a lack of published evidence of efficacy of pharmacotherapy in post-stroke fatigue. All told, the requested armodafinil (Nuvigil) is not medically necessary for treatment of this patients medical condition. 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 neurology with sub-specialty certification in sleep 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for genetic testing for hereditary breast and/or ovarian cancer syndrome (BRCA1/BRCA2) for evaluation of the enrollees risk for ovarian or breast cancer. Findings:  The physician reviewer found that There is a lack of support for the medical necessity of the requested services in this clinical setting. The American Congress of Obstetricians and Gynecologists criteria recommend a comprehensive initial screening for hereditary breast and ovarian cancer prior to initiating genetic testing. This patient does not meet the criteria recommended by these guidelines. The medical literature supports genetic testing for patients who do not have a personal history of breast cancer if she has a first degree relative diagnosed with breast cancer below the age of 45. This patient is 51 years old whose mother had breast cancer at age 46. Additionally, this patient is not an Ashkenazi Jew, and there was no other cancer history in her family noted. In sum, genetic testing for hereditary breast and/or ovarian cancer syndrome (BRCA1/BRCA2) is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica tablets for treatment of the enrollees chronic migraine headaches. Findings: The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication. Lyrica (pregabalin) has the same mechanism of action as gabapentin, and neither has been demonstrated to have efficacy in reducing migrainous headache activity preventatively. There are small, open-label or non-randomized placebo controlled studies demonstrating possible benefit. However, the largest meta-analysis by Linde and colleagues concluded that neither has efficacy. Accordingly, Lyrica is not medically indicated and is not likely to be more effective than alternatives available. Therefore, Lyrica 100 mg tablets 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 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 a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for medical services rendered in an urgent care.Findings: The physician reviewer found that the services at issue were not necessary for treatment of an emergency medical condition. No emergent condition was identified and no emergent treatment was provided. In this case, the patient presented to urgent care with symptoms that were not acute. The patients rash had been present for one month. The patients symptoms were not severe. There is no documentation of any difficulty breathing or swallowing. Given that the patients symptoms were not sudden or severe, the patients symptoms do not meet criteria for an emergency medical condition. As such, the services provided do not meet criteria for emergency medical services.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency 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 Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nuvigil 200 mg three times per day for treatment of the enrollees idiopathic hypersomnia. Findings:  The physician reviewer found that Currently, there are no U.S. Food and Drug Administration (FDA) approved medications for the treatment of hypersomnia. In addition, a comprehensive review of the current medical literature does not reveal any peer-reviewed publications supporting the use of dosing at 600 mg of Nuvigil for the treatment of idiopathic hypersomnia. The FDA cautions against the use of doses of Nuvigil greater than 250 mg daily. While the patient and her treating provider state the patient has experienced superior results with their preferred treatment modality, the use of Nuvigil at 600 mg daily dosing for the treatment of idiopathic hypersomnia is not supported by the medical literature. Thus, the requested Nuvigil 200 mg three times per day is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the requested medication dosage is 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 reviewer number one is board certified in oral and maxillofacial surgery with expertise in sleep medicin 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.Physician reviewer number two is board certified in neurology with sub-specialty certification in sleep 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.Physician reviewer number three is board certified in anesthesiology with sub-specialty certification in pain medicine and expertise in sleep 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for bilateral mastectomy for treatment of the enrollees gender dysphoria and were not reconstructive in nature. Findings:  The physician reviewer found that There is support in the medical literature for the services at issue in this clinical setting. This patient has documented gender dysphoria and is in the transition to becoming a male. The patients age should not be a sole determinant of medical necessity. The records note evidence of abnormal breasts for a male despite the use of hormonal therapy and would have not have likely resolved with continued therapy. An examination in February 2017 noted evidence of breasts that were consistent with the female gender. Since this patients condition would not have resolved even with hormone therapy, surgical intervention to treat this patients dysphoria was clinically appropriate. Therefore, the bilateral mastectomy performed on was medically necessary for treatment of this patients gender dysphoria. With regard to whether the services at issue were considered reconstructive in nature, the submitted documentation revealed that the patients breast development constituted an abnormal structure of a male body. The patients breast development should be more consistent with an adult male body. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. In this patients case, the abnormal breasts was a developmental abnormality for a male. This surgery is generally performed to improve function, but may also be performed to approximate an appearance more closely resembling a male chest, to the best extent possible. In this patients case, he had evidence of an abnormal chest for a male. The patients breasts should be more consistent with a male chest. As such, the surgery offered a more than minimal improvement in the appearance of this patients chest. All told, the bilateral mastectomy performed was reconstructive in nature. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition and were reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic 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.