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

Standard Review The parent of a transgender male enrollee has requested authorization and coverage for bilateral mastectomy with bilateral nipple areolar reconstruction (CPT codes 19350.50 and 19303.50). The Health Plan has denied this request indicating that the requested services are not medically necessary and are not reconstructive in nature for treatment of the enrollees gender dysphoria. 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.Nature of Statutory Criteria/Case Summary: The submitted documentation supports the medical necessity criteria for the requested services in this clinical setting. The surgical concept of treating breasts in individuals undergoing female to male reassignment surgery is well established and documented within the medical literature. However, each patient must be reviewed on a case by case basis to determine medical necessity. In this case, the patient has evidence of significantly abnormal breasts for a male that will not improve with continued hormonal therapy.  His photographs show evidence of grade III breast ptosis with significantly overlapping skin. He continues to experience significant gender dysphoria due to the appearance of his breasts. Therefore, the requested bilateral mastectomy with bilateral nipple areolar reconstruction is medically necessary for treatment of his medical condition.  With regard to whether the requested services are considered reconstructive in nature, reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be performed to approximate a normal appearance. Based on the patients gender dysphoria and identification as a male, a normal appearance of the breasts for a male is the ultimate goal. The proposed procedures are likely to create a relatively normal appearing male chest and would offer more than a minimal improvement in the appearance.  As such, the requested bilateral mastectomy with bilateral nipple areolar reconstruction (CPT codes 19350.50 and 19303.50) is reconstructive in nature for treatment of this patients gender dysphoria.  Final Result: The reviewer determined that the requested services are medically necessary and are reconstructive for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Epclusa 400/100 mg for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage.  In treatment-naive, genotype 2 patients, therapy is recommended with Epclusa, or Sovaldi with Daklinza, which is on the formulary.  There is a lack of controlled head-to-head comparison data to show that Epclusa is superior to Sovaldi with Daklinza.  Both Sovaldi and Daklinza can be crushed to deliver through a gastrostomy tube if needed.  The current guidelines cite data showing reduced survival with delayed treatment.  Final Result: The reviewer determined that the requested medication regimen is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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 Viibryd 40 mg 1.5 tablets for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that there is a lack of support in the submitted documentation for the requested medication dosage in this clinical setting. The rationale for the requested dose increase of the medication Viibryd is unclear. The provider indicated that the patient tried and failed multiple medications at high doses. However, those doses were not noted in the clinical records provided.  Moreover, the combinations of medications were not provided, and it appears that the only augmentation strategy was to add Abilify.  Moreover, according to records provided, the patients depression was reported to have increased, but later she reported that her depressive symptoms had improved, and her affect was described as `brighter`.  Her feelings of depression were described in relation to the binging episodes (going into a `terrible` mood after binging).  In short, the patient reported depressive symptoms after an episode of eating disorder behavior, thus rendering the current depression as situational in nature.  From the notes provided, her eating disorder symptoms appear to be the cause of the depression, and if that were to be treated, the depression may very well be ameliorated.  The provider increased her Vyvanse to 30 mg twice per day. Increasing an antidepressant will not necessarily treat a situational depression or mood lability. Rather, the increased Vyvanse and continuation of one on one therapy will be more effective to address her situational depressive symptoms.  As such, Viibryd 40 mg 1.5 tablets is not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested medication dosage 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genotype testing provided on 8/9/16.Findings:  Two physician reviewers found that the patient has a diagnosis of bipolar disorder. The patient reports to having a severe manic episode in mid-2015. She has received treatment at outpatient, intensive outpatient program (IOP), and partial hospitalization program (PHP) levels of care. She has also received treatment with electroconvulsive therapy (ECT). The provider indicated that the patient was unable to tolerate medications at therapeutic doses due to severe side effects, and she had lack of symptom relief. The patients previous medications included Geodon, Lamictal, Ativan, lithium, Depakote, and Ambien. The patient has requested reimbursement for genotype testing provided on 8/9/16. The Health Plan has denied this request as investigational. The testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Genetic testing results show if a patient is a normal responder of certain classes of medications, more or less likely to respond to certain medications, is at low risk of certain adverse events, at higher risk of others, or may have decreased activity of a certain enzyme activity. The fact that one of these results shows up on genetic testing does not indicate that one medication will, definitively, be more or less effective than another. There are other factors that influence medication efficacy such as drug-on-drug interactions and variance in hepatic metabolism of each individual. All of these factors are issues that can be assessed by the provider during follow-up, and adjusted for by changes in medication regimen including increased/decreased dose, augmentation strategies, or discontinuation for a variety of reasons. Studies have shown that clinically useful predictors in genetic testing are scarce for antidepressant therapy, with results being inconsistent and only marginal clinical association between enzyme system variants and drug metabolism, efficacy, and tolerability in the treatment of depression. Final Result: Two reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in psychiatry and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees risk of coronary artery disease. Findings:  The 3 physician reviewers found that the advanced lipoprotein testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this circumstance, guidelines for the management of cardiac risk have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of LDL, high-density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine (Greenland, et al; Stone, et al). Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  Therefore, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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 reimbursement and prospective authorization and coverage for continued intensive outpatient program level of care. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the services at issue.  The records indicate that the patient has remained sober throughout his treatment in the intensive outpatient program which he has consistently participated in for several months.  He has been cooperative, open and honest throughout treatment.  The records do not document severe psychiatric symptoms, and he has not been suicidal or homicidal during his time in the intensive outpatient program.  His medical problems appear to be under good control.  Based on the medical records, he could have been safely and effectively treated with outpatient services during the dates of service in dispute.  The clinical notes document motivation to change and a sustained period of sobriety.  There is a paucity of evidence to support superior benefit of intensive outpatient program level of care over outpatient treatment in this case.  All told, continued intensive outpatient program level of care  were not and are not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 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 Humira every week.Findings:  The physician reviewer found that clinical literature supports the use of Humira 40 mg weekly for the treatment of ulcerative colitis in this patients case. The submitted documentation notes that this patient did not have adequate response to Humira 40 mg every other week. In the ULTRA 1 trial, which was a high-quality, randomized, double-blind, placebo-controlled trial, weekly use of Humira allowed an increase in maintenance of remission. In the ULTRA 2 trial, it was part of the protocol to change patients to weekly Humira if response was not adequate on Humira every two weeks. The trial advanced responders and non-responders at week eight to weekly therapy. Both groups contained a fraction that responded to dosing frequency increase. In the ULTRA 3 trial, weekly Humira was started for inadequate response or for flare. In a subset analysis of ULTRA 2 patients, those on weekly therapy had week-52 response rate of 25% after failing therapy given every two weeks. These data apply to this patients case. The medical literature on the use of Humira for ulcerative colitis supports use of 40 mg weekly. For these reasons, the requested treatment with Humira weekly is supported as medically necessary for the treatment of this patient medical condition.Final Result: The reviewer determined that 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 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 reimbursement and prospective authorization and coverage for intensive physical therapy, occupational therapy, speech therapy, recreational therapy and all medications associated with current conditions.  Findings:  The physician reviewer found that functional impairments due to traumatically acquired brain insults improve with time, i.e., natural recovery processes.  These impairments are also amenable to rehabilitation interventions.  Nevertheless, deficits can remain severe, particularly in the setting of severe injuries.  A protracted period of functional dependency following intracerebral hemorrhage in particular can be high.  In this case, the patient sustained a severe traumatic brain injury.  He has made significant progress in multiple domains over a period of time, but continues to have significant deficits in cognition and carryover.  He continues to have ongoing rehabilitative needs, but these can be met at a less intensive setting of care than acute inpatient rehabilitation.  His course and outcomes are not expected to be marginally improved with a higher intensity of rehabilitative services at this time.  His prognosis for full functional recovery remains guarded on account of his underlying injuries.  He remains at risk for health-related complications regardless of care setting.  Notably, his treating providers have not recommended ongoing acute inpatient rehabilitation.  Further rehabilitative services are necessary going forward, but these services can be provided in a skilled nursing facility level of care.  There are otherwise no documented ongoing needs requiring ongoing care at the acute inpatient rehabilitation level with close physician supervision, specialized rehabilitation nursing services and intense multidisciplinary therapy services.  The acute inpatient rehabilitation in question is not medically necessary for this patient based on the available records.  Thus, intensive physical therapy, occupational therapy, speech therapy, recreational therapy and all medications associated with current conditions from date of dispute onward were not and are not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care services for treatment of her eating disorder. Findings:  The physician reviewer found that per the American Psychiatric Association (APA) guidelines, services available for the treatment of eating disorders can range from intensive inpatient settings to RTC and partial hospitalization programs to varying levels of outpatient care. Pretreatment evaluation of the patient is essential for determining the appropriate treatment setting. Patient weight, rate of weight loss, cardiac function, and metabolic status are the most important physical parameters for making this choice. This patient was admitted status post bowel impaction due to prolonged food restriction combated with re-feeding and weighed 72% of her ideal body weight (IBW) on admission. She continues to have high levels of anxiety, eating disorder behaviors, and abnormal labs. In addition, the patient has demonstrated slower than expected improvement in symptoms. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 requested reimbursement for electroconvulsive therapy (ECT) provided and inpatient hospitalization services provided when she received ECT for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that ECT is recognized as a safe, rapid and highly effective neuromodular intervention available for the treatment of severe affective illness, including both unilateral depression and bipolar disorder.  A typical index course of ECT consists of six to twelve treatments provided at a frequency of three treatments per week.  The intervention is endorsed by the American Psychiatric Association as a first-line treatment for depressive episodes.  However, this patients diagnosis was unclear as the progress notes listed psychotic disorder, not otherwise specified, and the illness burden was steeped in psychotic features.  ECT is not a first-line treatment for a formal thought disorder, and the presence of a severe affective episode was not established.  Additionally, critical documents to support the application of ECT were absent.  There was no specific evaluation or consultation for ECT.  Final Result: The reviewer determined that the services at issue were 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. Final Result: The reviewers determined that the service at issue was 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: the physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.