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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a bilateral mastectomy. Findings:  The physician reviewer found that chest surgery in transgender male minors is a common treatment for gender dysphoria. The World Professional Association for Transgender Health (WPATH) states, 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. Olson-Kennedy and colleagues reported that chest surgery in transgender male minors was a safe and effective treatment for gender dysphoria, noting, Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. Given these findings, professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age. In this case, the patient has gender dysphoria and has spent ample time living in the desired gender role and had one year of testosterone treatment. The patients providers report the requested services are medically indicated for the treatment of this patient. Therefore, 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 psychiatry with expertise in transgender health and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an enrollee has requested reimbursement for air and associated ground ambulance transportation.In order to be medically necessary, air ambulance transportation must meet the following criteria: the individuals condition must be such that any form of transportation other than ambulance would be medically contraindicated; the individuals condition is such that time needed to transport by ground poses a threat to the patients survival; the individual is transported to the nearest hospital with appropriate facilities for treatment; and there is a medical condition that is life-threatening. When transporting from one facility to another, the above criteria must be met, and the first hospital does not have the required services and facilities to treat the patient.In this case, the patient sustained a severe, acute traumatic brain injury without other significant concomitant injuries associated with long-term functional sequelae. The patient received critical care services in the early aftermath of the injury and was eventually stabilized sufficiently for rehabilitation-focused care. Due to the severity of the patients deficits and the intensity of his rehabilitative needs, he did require inpatient rehabilitation services. There was, however, no medical necessity for the patient to be transferred by air ambulance from the acute hospital in California, the first facility, to an out of state rehabilitation facility on the date of service. The patient could have been transported via a ground ambulance to an appropriate inpatient rehabilitation facility that was in closer geographic proximity to the originating acute hospital in California. This ground ambulance could have been equipped/staffed with the appropriate crew and support services that the patient needed in transit. No clinically or functionally significant difference in the patients long-term outcomes at an appropriate geographically proximate rehabilitation facility would have been reasonably expected in comparison to his outcomes following rehabilitation at the out of state facility to which he was transferred. Criteria for air ambulance transport were not met in this case. Therefore, air and associated ground ambulance transportation provided on the date of service were not medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary for the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patients parent has requested reimbursement for a second unit of deep sedation coded. Medical literature noted that the appropriate setting for sedation should be determined as there is an increased risk outside the hospital setting. Researchers found that the risk of adverse anesthesia complications is not increased when choosing between moderate and deep sedation/general anesthesia for adolescent patients undergoing third molar extraction. According to the records provided for review, the dental surgery was performed with deep sedation. The use of deep sedation for the procedure was appropriate given the removal of impacted teeth, while the previous procedure on involved removal of teeth numbers 1, 16, 17, and 32, which were not impacted. Deep sedation was provided to ensure that the patient did not move during the procedure and was consistent with the recommendations in the medical literature. All told, the second unit of deep sedation was medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injection series in the left knee. Findings:  The physician reviewer found that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of osteoarthritis of the left knee, refractory to conservative treatment, with the alternative being a total knee arthroplasty. The records showed excellent lasting relief from viscosupplementation injections in the past. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, an Orthovisc injection series in the left 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for enhanced external counterpulsation (EECP) therapy Currently, EECP is reserved for patients who have no percutaneous or surgical options for the treatment of angina and have failed or cannot tolerate angina treatment with guideline directed optimal medical therapy including higher dose beta blockers, long acting nitrates and calcium blockers and/or ranolazine.There is a lack of cardiac test results including catheterization and stress testing to delineate the extent and treatability of his coronary artery disease.  The pain is described as exacerbated with exertion and relieved with rest, but the level of exertion is not reported. There is also a lack of evidence that the patient has been treated with other anti-anginal agents including calcium blockers, long-acting nitrates, or ranolazine. His resting heart rate and his blood pressure allow for further medical therapy. Based on the available information, the patients condition is not consistent with refractory angina to support an indication for EECP. For these reasons, the requested EECP therapy is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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: The patient has requested authorization and coverage for prescription medication Trulance 3 mg tablet, once a day. Findings:  The physician reviewer found that the U.S. Food and Drug Administration approves the use of Trulance for the treatment of chronic idiopathic constipation (CIC). Miner and colleagues found that plecanatide was effective in improving constipation and its related symptoms with a low rate of adverse events. Chey noted that the American College of Gastroenterology (ACG) includes fiber, stimulant laxatives, and lubiprostone as evidence-based approaches to managing IBS and CIC. In this case, the patient has constipation without an identifiable cause on clinical examination or colonoscopy. Current guidelines recommend the use of stimulant laxatives and osmotic laxatives, and then advanced agents, such as Linzess and Amitiza. The current guidelines do not recommend attempting Trulance before the formulary alternatives Linzess or Amitiza. Therefore, prescription medication Trulance 3 mg tablet, once a day is 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for per-oral endoscopic myotomy (POEM) procedure. The records provided for review document achalasia with esophagogastric junction outflow obstruction and Jackhammer esophagus. Jackhammer esophagus is a manifestation of the hypertensive type of esophageal dysmotility. Contractions, as in this patients case, are high amplitude, and involve most of the esophagus. Symptoms may include dysphagia and chest pain. As with this patient, Jackhammer esophagus can progress to achalasia, which is a motility disorder of the esophagus characterized by the absence of peristalsis and a defective relaxation of the lower esophageal sphincter (LES). Current treatment options of achalasia are directed at relieving the functional obstruction at the level of the LES. Bhayani and colleagues compared Heller myotomy with the POEM procedure. The authors found that POEM required a shorter hospitalization while patient symptoms and esophageal physiology were equally improved with both procedures. Talukdar and colleagues aimed to determine comparative efficacy of POEM versus laparoscopic Heller myotomy. Minami and colleagues reported that, POEM could be a curative standard treatment of choice for esophageal achalasia. Given these findings, the requested POEM procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested POEM procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for eight infusions of Tepezza. Findings:  The physician reviewer found that Tepezza (teprotumumab) is a newly approved therapy for active thyroid eye disease. Ting and Ezra state that teprotumumab may herald a new era in the treatment of thyroid eye disease and could offer an alternative to surgery and its associated complications. Ju and Yang state that teprotumumab is a human insulin-like growth factor-I receptor monoclonal inhibitor antibody which is indicated for treating thyroid eye disease. They note that clinical trials indicated that proptosis response of teprotumumab was 83%, and clinical activity score, diplopia, and quality of life were also better than placebo. In this case, the patient has severe or sight threatening thyroid eye disease which appears to have had progression of her proptosis and lid retraction for which another orbital decompression is planned. The patient continues to have pain, conjunctival redness and eyelid swelling and redness, which are all signs of inflammation (based on these findings, her clinical activity score is 4 out of 7). Accordingly, the patients condition is active with signs of inflammation. Therefore, the use of Tepezza in this patient with active disease who has failed prior therapies is medically necessary. Accordingly, the requested eight infusions of Tepezza are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in ophthalmology 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

A 45-year-old enrollee who has been diagnosed with focal partial idiopathic epilepsy and hyponatremia. An electroencephalogram (EEG) in 2020 was noted to be abnormal with frequent right frontal and bifrontal epileptiform discharges. In June 2020, the provider noted that the patients sodium level was 130 mEq/L, and a switch from the medication Oxtellar to Aptiom was recommended due to the patients high frontal activity. The provider noted that the patient had one seizure in March 2020. The patient has requested authorization and coverage for Aptiom 800 mg tablets. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient.  At issue in this case is whether Aptiom 800 mg tablets are medically necessary for the treatment of the patients medical condition. Medical literature reported, Eslicarbazepine acetate (ESL), is a once-daily, oral antiepileptic drug (AED) for the treatment of focal (partial) onset seizures in patients four years of age or older. ESL is a member of the dibenzazepine carboxamide class of putative voltage-gated sodium channel blocking AEDs, which also includes carbamazepine and oxcarbazepine. Hyponatremia (i.e., low blood sodium) may occur with the used of dibenzazepine carboxamide AEDs. Researchers  reported, Carbamazepine and oxcarbazepine are the most common AEDs which induce hyponatremia in patients with epilepsy. Recently, other AEDs, such as eslicarbazepine, sodium valproate, lamotrigine, levetiracetam and gabapentin have also been reported to cause hyponatremia. In this case, the provider recommended a switched from the medication oxcarbazepine (Oxtellar) to eslicarbazepine (Aptiom) for the treatment of the patients focal partial idiopathic epilepsy. The patient has also been diagnosed with hyponatremia. The providers rationale for switching from Oxtellar to Aptiom appears to be related to the patients hyponatremia. However, both medications are known to cause hyponatremia. As such, the patient is not likely to benefit from this medication change. The medical evidence does not support the requested medication in this clinical setting. Therefore, Aptiom 800 mg tablets are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for nose reconstruction surgery (CPT 30450  rhinoplasty secondary major revision; 21230  graft rib cartilage autogenous face/chin/nose/ear). The records provided for review support the presence of a functional complaint with physical examination findings consistent with a functional issue given the presence of both internal and external nasal valve collapse. Additionally, the two prior surgeries were reportedly undertaken for a functional issue, and the second surgery was related to a traumatic event. The proposed surgery is typically undertaken to improve function by opening the nasal airway. The proposed grafts are to open the nasal airway at the internal nasal valve, and to prevent the nostril from collapsing during inspiration. Furthermore, as the patient has already undergone a prior septoplasty, and prior ear cartilage graft harvest at his previous two procedures, use of costal cartilage is an appropriate graft option. Given these findings, the requested nose reconstruction surgery (CPT 30450  rhinoplasty secondary major revision; 21230  graft rib cartilage autogenous face/chin/nose/ear) is medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. The medical records note that this patient has a history of nasal obstruction and trauma that has been treated with nasal steroid sprays and two surgeries. The requested surgery will address the patients functional issues and was recommended to improve the patients breathing. All told, the requested nose reconstruction surgery (CPT 30450  rhinoplasty secondary major revision; 21230  graft rib cartilage autogenous face/chin/nose/ear) is reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature 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:  The patient has a history of blepharitis and has failed treatment with eyelid hygiene and topical steroids. While treatment with oral doxycycline and a lower anti-inflammatory dosage is supported, the records do not demonstrate that the patient would experience side effects with the standard form of the drug. As the standard form of this medication is typically tolerated without side effects, the delayed-release form of the medication is not medically indicated. Therefore, doxycycline hyclate delayed-release is not medically necessary for the treatment of this patient. Final Result: The reviewer determined the medication at issue 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 ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement for facial hair removal services (electrolysis epilation). Facial hair removal is a common treatment for gender dysphoria that helps with social functioning. The World Professional Association for Transgender Health (WPATH) lists hair removal, through electrolysis, laser treatment, or waxing, as an option to help alleviate gender dysphoria. In this case, the patients providers supported the medical necessity of facial hair removal services to treat the patients gender dysphoria. Therefore, facial hair removal services (electrolysis epilation) were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for eight hours per month of clinical team meetings. Based on the available documentation, this patient is engaging in few, if any, problem behaviors. The records report one tantrum in six months, zero incidents of aggression and property destruction per hour, and .02 incidents of self-injury and elopement per hour. The patients provider has recommended eight hours of clinical team meetings per month as part of her applied behavioral analysis (ABA) treatment regimen. The Behavior Analyst Certification Board (BACB) guidelines do not include team meetings as part of an ABA treatment plan. The BACB guidelines highlight that a review of programs can occur without the patient but can also occur with the patient present. Moreover, the requested clinical team meetings do not meet the medical necessity criteria outlined by Papatola and Lustig. The authors noted that medically necessary services include health-care services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Applying these guidelines, this patient does not meet the requirements or (a) or (c). Specifically, the requested services are not required to meet the essential health needs of the patient and are not consistent with scientifically based guidelines as determined by medical research. All told, the requested eight hours per month of clinical team meetings are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is a licensed B.C.B.A, board certified in psychology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.