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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for endovenous radiofrequency ablation.  The enrollee has varicose veins with inflammation in both legs. Her symptoms include edema to her ankles, bulging veins and pain. Findings:  The physician reviewer found that literature specifies appropriate candidates for laser ablation for the treatment of lower extremity chronic venous disease are those with persistent symptoms and signs of venous disease after a trial of medical therapy, and documented reflux, as demonstrated by a retrograde flow greater than 0.5 seconds duration, as a source of their symptoms.  This treatment protocol is recommended for treatment of patients with these indications and for patients with symptoms refractory to conventional treatment. 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 Vascular 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Harvoni 90-400 mg tablets once daily for eight weeks for treatment of hepatitis C. The American Association for the Study of Liver Diseases and the Infectious Diseases Society of America recommends treatment for all patients diagnosed with chronic hepatitis C virus (HCV) infection, except those with a short life expectancy that cannot be remediated by HCV treatment, liver transplantation, or another directed therapy. One study reported that since 2013, all-oral, interferon-free regimens with direct-acting antivirals have quickly become the mainstay of treatment for HCV infection as they provide high rates of sustained virologic response with a relatively short duration of treatment and low side effect profile. In this case, the patient was diagnosed with hepatitis C with a Metavir score of F0-F1. The medical evidence supports the requested medication in this clinical setting. Therefore, Harvoni 90-400 mg tablets once daily for eight weeks 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for biofeedback therapy Findings:  Two of the three physician reviewers found that there is sufficient support for the requested services in this clinical setting. Neurofeedback is a specific form of biofeedback that involves an encephalogram (EEG). This modality is utilized to improve brainwave activity, particularly in patients with anxiety disorder. The study by Surmeli and Ertem evaluated 36 patients with obsessive-compulsive disorder who were treated with neurofeedback. Per the authors, 33 out of 36 patients who received neurofeedback training showed clinical improvement. The authors noted that the study provided good evidence for the efficacy of neurofeedback treatment in obsessive-compulsive disorder. In this patients case, despite psychotherapy and Lexapro, he continues to be symptomatic. Treatment with biofeedback is appropriate in this clinical setting. In sum, biofeedback therapy is likely to be superior over other treatment options. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and are actively practicing. Physician reviewer 2 is board certified in psychiatry 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facial feminization surgeries. The World Professional Association for Transgender Health (WPATH) lists facial feminization surgery as a medically necessary gender affirming surgery. Specifically, the WPATH states that, non-genital surgical procedures...notably facial feminization surgery...are often of greater practical significance in the patients daily life than reconstruction of the genitals. Further, the WPATH asserts that these reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. A study reported that facial feminization, like genital surgery, improved mental health quality of life. The records provided for review document clinically significant symptoms due to gender dysphoria related to masculine features of her face. The patient meets the WPATH criteria for gender dysphoria and indication for facial feminization surgery based upon clinical documentation of persistent gender dysphoria related to masculine facial features. Therefore, the requested facial feminization surgeries are supported as medically necessary for treatment of this patients distress related to gender dysphoria. Final Result: The reviewer determined that the requested surgeries 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xyosted. This patients records document low testosterone secondary to testicular hypofunction. He failed to improve with topical testosterone replacement therapy. He demonstrated clinical improvement with Depo-testosterone injection therapy. However, he is unable to tolerate the injections. The patient would prefer the subcutaneous testosterone enanthate autoinjector (SCTE-AI) therapy with Xyosted. Xyosted auto-injectors have been shown to be effective for testosterone replacement therapy and are approved by the U.S. Food and Drug Administration (FDA) for this purpose. One study found that SCTE-AI offers a testosterone delivery system that is a convenient weekly option to treat testosterone deficiency. Medical literature reported that the SCTE-AI device is safe and intuitive to use, with a low potential for harm and is associated with a high rate of injection success, regardless of prior training or experience. Given this patients prior failure with topical creams and sildenafil, the requested Xyosted is medically necessary for the treatment of patients testicular hypofunction.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 urology 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 requested authorization and coverage for custom foot orthotics. The Health Plan denied the request and reported the requested orthotics are not medically necessary for the treatment of this patient. At issue in this case is whether custom foot orthotics are medically necessary for the treatment of the patients medical condition. Plantar fasciitis is diagnosed based on the patients history and examination. The initial treatment is conservative, focusing on alleviation and resolution of the foot pain. Initial treatment modalities include taping, icing, proper footwear, stretching, and rest. The recommended orthotics with the additional application pads represent specialized applications to help alleviate foot pain. The requested orthotics include a metatarsal bar, an outflare wedge, a heel stabilizer, and heel depression for a calcaneal spur. Orthotics with these types of applications have been used as the standard of care conservative treatments for patients with plantar fasciitis and pes planus. The requested orthotics alter the biomechanics of the foot, allowing for pain-free range of motion and ambulation. In this case, the patient was diagnosed with congenital pes planus bilaterally, plantar fasciitis, and right foot pain. The patients current orthotics are worn, and he reported bilateral heel pain. The medical evidence supports the requested orthotics in this clinical setting. Therefore, custom foot orthotics are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested devices 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 podiatry 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 is requesting authorization and coverage for a procedure to surgically remove the varicose veins. The enrollee has bilateral lower extremity varicose veins. The record indicates she is experiencing a sense of swelling, heaviness, and pain in her legs when she tries to work out. Her symptoms are advancing despite wearing compression hose. The pain is interfering with her ability to work and becomes so intense as to make her physically ill. Findings: . Her physician documented a cluster of moderate-sized varicose veins on the medial aspect of her right leg, varicosities in the proximal medial thigh with vulvar varicosities, and varicosities measuring over 6 mm in size on the medial aspect of the left leg and thigh. Ankle swelling is minimal. She has no reflux in the greater saphenous vein. The physician suspects some pelvic reflux due to the proximal medial thigh varicosities. Notes indicate the possible need for future intervention for the pelvic reflux. However, the physician wants to treat only the symptomatic veins with stab phlebectomies. According to the medical literature, the indications for ambulatory phlebectomy include asymptomatic varicose veins for cosmetic purposes, symptomatic varicose veins not responding to conservative treatment, and enrollees with complications of varicose veins, such as superficial thrombophlebitis, recurrent thrombophlebitis, and bleeding. Stab phlebectomy involves the removal of varicose tributaries. It is a well-described and standard approach in these settings. Based on the enrollees physical examination, her condition was debilitating due to bulging veins and throbbing that made her physically ill and faint. She had to wear compression tights all year round.  The literature supports the performance of the requested procedure for enrollees such as this one as she did not have reflux, but had objective findings. 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 Vascular 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for single photon emission computed tomography dopamine transporter (SPECT-DAT) scan.  Examination showed a resting tremor, mild cogwheel rigidity of the right arm and slower fine motor function of the right hand. The neurologist ordered magnetic resonance imaging (MRI) of the brain and a Single Photon Emission Computerized Tomography Dopamine Transport (SPECT-DAT) scan to clinically establish a diagnosis. The SPECT-DAT scan was positive for dopaminergic abnormality. These results were consistent with Parkinsons disease. Findings:  The physician reviewers found that according to practice guidelines, clinical indications for SPECT-DAT for the evaluation of movement disorders include differentiation of parkinsonian syndromes (PS) from essential tremor in patients with worsening symptoms and diagnostic confirmation when diagnostic uncertainty exists. An accurate diagnosis of PS is critical for clinical management; misdiagnosis can occur in up to 10% of cases. This can lead to unnecessary disability or inappropriate treatment. SPECT-DAT can reliably distinguish patients with Parkinsons disease (PD) and other parkinsonian syndromes associated with nigrostriatal degeneration. It is considered reasonable for patients in whom the diagnosis is unclear after clinical evaluation. It was approved for striatal dopamine transporter visualization to assist in the assessment of adult patients with suspected parkinsonian syndromes. Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in neurology 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 Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronan injections to the left knee. Findings:  The physician reviewer found that the requested services are medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.This enrollee has osteoarthritis and has failed other treatments. The enrollee has benefitted from viscosupplementation with Synvisc One in the past. The current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit.  Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence does not support viscosupplementation as a standard treatment for osteoarthritis of the knees. Viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. In this enrollees case, prior viscosupplementation has been beneficial, and her options are limited. The enrollee has tried and failed other conservative treatments, including corticosteroid injections. Therefore, hyaluronan injections to the left knee are medically necessary for the treatment of this enrollee.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the enrollees 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has bilateral lower extremity pain due to myofascial pain syndrome. Findings: The physician reviewer found that the requested service is not medically necessary for the treatment of the enrollees medical condition.  Calf pain and spasms are exacerbated when the enrollees knees are bent in the sitting position. Other pain triggers are fatigue, dehydration, and exercises that contract posterior leg muscles. Her pain was primarily controlled with pain medications, but stretching and exercises also improved symptoms. She completed a reconditioning group, which resulted in changes to her physical functioning; such as increased activity, increased stretching, and improved body mechanics. Her physiatrist believes she has benefitted from proprioceptive-deep tendon reflex (P-DTR) therapy and feels she would continue to benefit with further treatments. According to the companys information, P-DTR is a unique neurological therapy based on neurology, biomechanics, neurophysiology, anatomy and profound research. It works directly with the central nervous system and has a logical scientific explanation for all of its teachings. It is constantly being researched, and the scope of practical application of its unique material is being expanded on a yearly basis. However, review of the literature indicates there are no clinical trials, case series, or narratives in the published peer reviewed literature that discuss P-DTR. There is a report of a conference, but it is not a structured, scientific report. There is no learned society that has published any recommendation for this method and there is no published research. A search of a nationally recognized website for complementary medicine revealed no information for proprioceptive-deep tendon reflex.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation and 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for an Immunoassay for Analyte other than infectious agent antibody or infectious agent antigen; quantitative. The enrollee was seen by her physician for complaints of mood swings, hot flashes, weight gain and bilateral knee pain. Exam showed severe aching/painful joints, severe joint swelling, and muscle and joint stiffness upon awakening. Her physician ordered a Veridia blood test due to concerns for rheumatoid arthritis. The Veridia Diagnostics revealed high C-reactive protein (CRP) levels. Findings:  The physician reviewers found that released in response to inflammation, this protein may be elevated in enrollees with type 2 diabetes, periodontal disease, sleep apnea, autoimmune disorders, women on birth control pills, or smokers. Review of the record indicates the provider ordered the Veridia test panel to rule out rheumatoid arthritis (RA). However, the enrollee did not meet rheumatoid arthritis classification criteria for this diagnosis. Her C-reactive protein (CRP), while borderline, was within normal limits. The diagnosis of RA results from a thorough history of joint pain and stiffness, and confirmation of symmetric polyarticular joint swelling (synovitis) by physical exam. Laboratory tests, such as biomarkers, are used as diagnostic confirmation of physical exam results. The Veridia test panel is not a widely accepted, standard-of-care diagnostic that has been proven to be more effective for the evaluation and treatment of this members symptoms than other diagnostics. The use of anti-cyclic citrullinated peptide antibodies (anti-CCP) testing as a diagnostic measure is routine clinical practice. There is insufficient documentation in the record supporting a diagnosis of RA and the pretest probability of having an abnormal result on the requested diagnostic was low.Final Result: Three of the three reviewers determined that the requested service was not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in rheumatology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine. The first appropriate imaging for the evaluation of low back pain with radicular symptoms is lumbar radiographs. According to the American College of Radiology, if the pain persists after four to six weeks of conservative management, and the patient is a surgical or intervention candidate, then MRI of the lumbar spine is the usually appropriate next examination. In this case, the records do not document four to six weeks of conservative management, which would include physical therapy, nonsteroidal anti-inflammatory drugs or exercise. There is documentation of a chiropractic visit in April 2018. The records document two physical therapy visits. The patient presented for physical therapy in June 2019. The initial plan was for six weeks of physical therapy. There is no documentation that this course of physical therapy was completed. At this time, MRI is not medically indicated. Therefore, the requested MRI of the lumbar spine 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 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.