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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for bilateral mastectomy. World Professional Association for Transgender Health (WPATH) criteria for chest surgery state that chest surgery in female-to-male patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescents specific clinical situation and goals for gender identity expression.Based upon the clinical history and documentation provided, this patient meets the WPATH criteria for breast surgery. This patient has been on testosterone therapy since March 2016 and has been living in the chosen gender role for greater than one year. Based on the documentation provided, this patient understands the risks, benefits, limitations and alternatives to surgery. His medical, mental health, and surgical providers are also supportive. Based on the records, surgery is medically necessary to align his body with his gender identity. Surgery would allow for him to stop binding, which is causing him discomfort and skin irritation and will likely help address his social anxiety. Therefore, the requested bilateral mastectomy 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and expertise in transgender care 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 facial feminization surgeries (rhinoplasty, adjacent tissue transfer (hairline advancement), repair of brow ptosis, reduction forehead, contouring only, genioplasty, and jaw taper). World Professional Association for Transgender Health (WPATH) criteria for surgery state that other surgeries for assisting in body feminization include reduction thyroid chondroplasty (reduction of the Adams apple), voice modification surgery, suction-assisted lipoplasty (contour modeling) of the waist, rhinoplasty (nose correction), facial bone reduction, face-lift, and blepharoplasty (rejuvenation of the eyelid). Other surgeries for assisting in body masculinization include liposuction, lipofilling, and pectoral implants. Voice surgery to obtain a deeper voice is rare but may be recommended in some cases, such as when hormone therapy has been ineffective. Although most of these procedures are generally labeled purely aesthetic, these same operations in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a given patients condition and life situation. This ambiguity reflects reality in clinical situations, and allows for individual decisions as to the need and desirability of these procedures.The submitted documentation, including transgender surgical evaluation and psychiatric evaluation, support that the patient meets the above WPATH criteria. She has had gender dysphoria since childhood and has lived full-time as a female. The psychiatric evaluation suggests that patient is dysphoric with incongruent facial features which are noted to be socially disabling. Therefore, the requested facial feminization surgeries (rhinoplasty, adjacent tissue transfer (hairline advancement), repair of brow ptosis, reduction forehead, contouring only, genioplasty, and jaw taper) are 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and expertise in transgender care 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 Adcirca at 50 mg daily. The enrollee has severe symptomatic pulmonary hypertension that after evaluation was thought to be idiopathic (World Health Organization [WHO] Group 1 pulmonary hypertension). Tadalafil (Adcirca) is FDA approved and indicated to improve exercise ability in WHO Group I PAH patients. According to researchers, in the PHIRST-1 trial, patients taking Adcirca 40 mg achieved a 33-meter improvement in six-minute walk distance compared to the placebo group and experienced less clinical worsening (defined as death, lung transplantation, atrial septostomy, hospitalization because of worsening PAH, initiation of new PAH therapy, or worsening WHO functional class) compared to the placebo group. researchers explain that current guidelines also consider tadalafil reasonable and appropriate treatment in this patient population. However, there is no indication in the medical records, or any of the documentation provided, to exceed the recommended dose of 40mg daily. Therefore, the requested medication dosage is not medically necessary for treatment of this patients condition. Final Result: The physician reviewer determined that the requested medication dosage is not medically necessary for treatment of the enrollees condition.Credentials/Qualifications: The physician reviewer is board certified in cardiology 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 power wheelchair (group 3 heavy-duty, multiple option, sling/solid seat/back).  According to the Official Disability Guidelines (ODG), power mobility devices are recommended if the functional mobility deficit cannot be sufficiently resolved by the prescription of a cane or walker, the patient does not have sufficient upper extremity function to propel a manual wheelchair, or there is not an available caregiver willing and able to provide assistance with a manual wheelchair. Colleagues concluded that powered mobility device interventions mainly contribute to mobility-related participation by making participation easier for people with mobility restrictions and by increasing the frequency of aspects of participation (such as shopping for groceries and going for a walk/ride). The study conducted by colleagues further strengthens the current evidence that powered mobility devices increase mobility-related participation in daily life among certain subgroups of adults with mobility restrictions.Current evidence based medical guidelines and peer reviewed literature support this request based on his medical condition, limited mobility and strength, and to maximize his independent function. There is no evidence that his medical condition had improved over the past four years in order to support a different level of power mobility device. Therefore, the requested group 3 power wheelchair is medically necessary for treatment of the enrollees medical conditions. Final Result: The reviewer determined that the requested equipment 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 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

An enrollee has requested authorization and coverage for corneal transplant with laser to be performed at one location, instead of two. The submitted documentation supports the medical necessity of the requested services. While there is a paucity of studies that have specifically compared laser keratoplasty procedure performed at two different sites versus one site, transporting the patient from one site to another during the procedure does add a small risk to the procedure. Therefore, in order to minimize risk of any harm to the patient, the one site procedure is recommended. Thus, the requested corneal transplant with laser to be performed at one location, instead of two, is medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lynparza (olaparib). Findings:  Three physician reviewers found that men with metastatic prostate cancer and a BRCA2 mutation are known to have a poorer prognosis compared with those without a BRCA2 mutation, although these prostate cancers may have a better response with appropriate therapy. Olaparib is not U.S. Food and Drug Administration (FDA) approved for the treatment of BRCA1 or BRCA2 positive prostate cancers nor does it carry off-label support by major drug compendia. It is the ongoing subject of clinical trials which are still recruiting patients. Preliminary results have shown that these patients may respond to treatment with a poly-adenosine diphosphate ribose polymerase (PARP) inhibitor. However, it is unclear how this treatment compares to other second-line therapy. There are other standard medications that this patient has not exhausted. In sum, Lynparza (olaparib) is not likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested medication 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 authorization and coverage for LINQ heart monitor implantation for symptom review and mapping of hearth rhythm (for cardiac ablation). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees condition. Findings:  The physician reviewer found that established indications for implantable cardiac monitors in current practice include unexplained syncope, palpitations, and management of atrial fibrillation. According recent literature, an expert consensus statement recommended a range from 24 to 48 hours to two weeks of ambulatory electrocardiographic monitoring for unexplained palpitations, depending on symptom frequency. Therefore, implantable monitors are not routinely indicated. This patient has documented frequent premature ventricular contractions with symptoms of persistent palpitations unresponsive to verapamil. If there remains a question as to the etiology of his symptoms beyond premature ventricular contractions, then more prolonged monitoring with standard devices could be considered. Moreover, an implantable loop recorder is generally considered appropriate for patients with recurrent syncope of uncertain cause or cryptogenic stroke with suspicion of paroxysmal atrial fibrillation, neither of which have been documented in this patient. This patient has not had the requisite indications for the justification of an implantable cardiac monitor.  Final Result: Two of the three reviewers determined that the services at issue were 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/QualificationsAll three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment. The submitted documentation fails to demonstrate the medical necessity of the services at issue. At the time of denial of coverage, the patient had participated actively in treatment. She had stabilized her weight and was not purging or binging.  Treatment goals can often effectively be accomplished in the outpatient setting. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) may assist in determining necessary level of care for children. With regards to risk of harm, the records support a score of 1. This patient demonstrated a low potential for risk of harm. She had no history of violence toward others. In terms of functional status, the records support a score of 1. The patient was engaged and active in treatment, not known to be purging or restricting. With regards to comorbidity, the documentation supports a score of 2. The patient had minor comorbidity. In terms of level of stress of the recovery environment, the records support a score of 1. There is no evidence of environmental threats, deprivation, or lack of financial support. With regards to level of support of the recovery environment, the records support a score of 2. The patients parents had recognized concerns regarding the patients weight, and had financially supported her treatment. In terms of resiliency and treatment history, the records support a score of 1. The patient was fully engaged with treatment per progress notes. With regards to acceptance and engagement of the patient, the records support a score of 1. Per the records, the patient was engaged and motivated for success in treatment. In terms of acceptance and engagement of the parent, the records support a score of 3. Per the patients report, her parents appeared to be judging rather than listening. Therefore, the patient has a composite score of 12, with no scores in the high risk range. Thus, the records do not support the medical necessity of residential treatment in this case. Therefore, residential treatment was not medically necessary for the treatment of this patient. 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 with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for monitored anesthesia. In this case, the medical needs of the patient do not support that the services in issue were medically necessary. According to the American Society of Anesthesiologists (ASA) guideline for anesthesia care during endoscopic procedures, monitored anesthesia care is warranted in prolonged or painful procedures such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. Additionally, the ASA guidelines state that monitored anesthesia care is more likely necessary in patients with failed history of moderate sedation for the procedure or psychological impediments to cooperation. According to the most recent guidelines from the American Society for Gastrointestinal Endoscopy (ASGE), during endoscopic procedures (unlike surgery) consciousness during the procedure is acceptable and is the goal during most procedures (which are performed with moderate sedation), and monitored anesthesia care is recommended for prolonged procedures requiring deep sedation, previously anticipated intolerance to standard sedatives, ASA class IV or V, or risk for airway obstruction due to anatomic variant. The provided records do not support any of these criteria, or other criteria in the literature, such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, age >70, pregnancy, increased aspiration risk, ASA class III or higher, or morbid obesity. For these reasons, the provided patient records do not support the medical necessity of monitored anesthesia care over short-acting sedation in this case.Final Result: The reviewer determined that the services in 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 internal medicine, with subspecialty 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services provided from 1/25/17 through 6/07/17. The Health Plan has denied this request indicating indicates that the enrollees condition does not meet the emergency and medical necessity criteria for the services at issue. Findings: The patient presented for an initial psychotherapy consultation on 1/18/17. Her diagnoses included panic, major depressive disorder, and obsessive-compulsive disorder. Her symptoms included poor self-regulation, impulsivity, irritability, and reported difficult coping with life stressors. Given her assessment on 1/18/17, there is ample evidence to argue for the medical necessity of ongoing regular psychopharmacology and psychotherapy treatment. Maintenance psychotherapy was appropriate to treat this patients condition, is consistent with good medical practice and is medically necessary.  After months of treatment, this patients condition cannot by definition, be an emergency.  Though it might be important and medically necessary, it should not be covered under the emergency provisions for this patient, but rather it should be diagnosed as necessary non-emergent treatment. The treatment provided does not meet the definition of emergency services as defined by the California Health and Safety code. Therefore, the services at issue were not necessary for treatment of an emergency medical condition. Final Result: The reviewer determined that the services at issue were not emergency medical services 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: The parent of an enrollee has requested authorization and coverage for Genotropin.Findings: Two of the three physician reviewers found that the requested medication is not indicated under these circumstances. The patient, labeled as idiopathic short stature (ISS), most likely has had a normal variant of constitutional delay of growth and development based on his clinical course and his normal growth velocity prior to receiving recombinant human growth hormone (rhGH) treatment. The FDA has approved only rhGH to treat ISS, and the various FDA-approved formulations of rhGH are bioequivalent. While receiving rhGH for ISS, this patient entered puberty. Now beyond the midpoint of puberty, he recently displayed a height percentile above his mid-parental target height (MPTH) percentile. It appears doubtful that this patient still requires exogenous rhGH to attain a height within 1.5 standard deviations of his MPTH. No FDA-approved formulation of rhGH for daily administration, such as the requested medication, Genotropin, is likely to be more beneficial than another FDA-approved formulation for daily treatment of this patient with a history of short stature. Specifically, the requested medication (Genotropin) is not likely to be more beneficial for treatment of the enrollees medical condition (neither ISS nor constitutional delay) than any available standard therapy of daily rhGH.Final Result: The reviewers determined that the requested medication 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: All three reviewers are board certified in pediatrics, with subspecialty certification in pediatric endocrinology, and all three 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.