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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for sclerotherapy for treatment of the enrollees vascular ectasias. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the service at issue. In this case, the patient has vascular ectasias, also known as telangiectasias and reticular veins, of the lower legs and feet. The documentation submitted for review does not demonstrate the patient has a diagnosis of bleeding or ruptured superficial varicose veins or skin ulceration or residual symptomatic superficial varicosities after vein stripping or ablation. In this clinical setting, the service at issue was cosmetic and not medically necessary. For the reasons provided, the sclerotherapy was not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the service at issue was 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 dermatology 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 parent of an enrollee has requested authorization and coverage for bilateral mastectomy for treatment of his gender dysphoria.  Findings: The physician reviewer found that the documentation provided supports the requested services in this clinical setting. Based on the documentation provided, the patient has gender dysphoria and is transitioning to the male gender. This patient has female breasts that would not likely resolve with continued hormonal therapy. Chronological age is not as important as the level of pubertal development in this patients case. The patients breasts appear to be consistent with a female. Hormone therapy will unlikely resolve this patients breast enlargement.  Since the condition will not resolve even with hormone therapy, surgical intervention to treat this patients dysphoria is medically reasonable and appropriate.  This patient has evidence of abnormal breasts for a male and his medical condition will not likely improve with continued hormonal therapy. Therefore, bilateral mastectomy is medically necessary for treatment of this patients gender dysphoria. With regard to whether the requested services are considered reconstructive in nature, the submitted documentation reveals that the patients breasts constitute an abnormal structure of a male body. 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 patient has evidence of abnormal breasts for a male as he is documented to have female Tanner stage V breast development. As such, the patients breasts are considered a developmental abnormality in a male. The plan of the surgery is to create a more normal appearance for a male chest. The requested services would create a relatively normal appearing male chest and would offer more than a minimal improvement in the appearance. For these reasons, bilateral mastectomy is reconstructive in nature and not cosmetic. 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. 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hour long weekly physical therapy appointments for treatment of the enrollees medical condition. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the services at issue in this clinical setting. At present, treatment recommendations generally revolve around relative rest, stretching, strengthening exercises, and passive modalities for palliation and improved tolerance for exercise. Eccentric load training is generally considered an appropriate measure for relieving symptoms and improving outcomes. In this patients case, he has undergone surgery and extensive physical therapy. He continues to have some symptoms but is able to ambulate significant distances independently. He has undergone sufficient therapy to be educated on independent stretching and strengthening exercises, including training in eccentric exercises. The records show that he can predominately perform independent exercises, receive modalities independently and perform self-massage, with no anticipated marginal difference in clinical course or outcomes versus exercises, manual therapy and modalities received in frequent and long therapy sessions in a formal setting. The literature does not support a proven benefit of long-term, high-intensity therapies, including manual therapy, in the setting of Achilles tendinopathy or post-tendon repair with respect to health or functional outcomes. For these reasons, hour long weekly physical therapy appointments are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma gene expression classifier for the evaluation of his indeterminate thyroid nodules. Findings:  Three physician reviewers found that Fine Needle Aspiration (FNA) is a well established procedure in determining if a thyroid nodule is malignant or benign with good sensitivity for a papillary thyroid cancer. This testing is supposed to help in planning future intervention. The negative predictive value is higher in this test but the literature has shown that the positive predictive value is low. The Afirma gene expression classifier potentially can improve the net health outcome by providing an alternative to diagnostic thyroid surgery. While there is some support for its use in this clinical setting, there is still insufficient data to confirm the superior efficacy of this testing over Fine Needle Aspiration (FNA). As such, long-term outcome data is still needed to support clinical and histologic outcomes. In this patients case, when the initial cytopathology was indeterminate, a repeat Fine Needle Aspiration (FNA) had been sent for cytopathology was interpreted as benign. In sum, due to insufficient long-term outcome data as well as the clinical documentation, the gene testing performed was not likely to have been more beneficial than the available standard. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for the 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 authorization and coverage for custom orthotics. Findings: The physician reviewer found the current guidelines indicate that orthopedic footwear including shoes, inserts, or modifications to shoes for patients without diabetes are not considered medically necessary. Some bracing may be indicated if the braces are on a shoe that is an integral part of a medically necessary leg brace. These criteria are not supported in the documentation provided. Review of the documentation provided does not indicate that the foot orthotic would alleviate the patients condition and therefore the requested custom orthotics are not medically necessary. Final Result: The reviewer determined that the requested equipment 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 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: An enrollee has requested authorization and coverage for Harvoni 90/400 mg for treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Thus, Harvoni 90/400 mg is medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested medication regimen 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for 12 weeks for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials. The medication regimen is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of the patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication regimen 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 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 tamsulosin HCL.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has pelvic floor dysfunction. The provider wishes to treat urinary hesitancy with alpha blockers. Multiple alpha blockers are available to treat this condition. These include tamsulosin, alfuzosin, terazosin, doxazosin and silodosin. Current medical literature does not support the superior efficacy of tamsulosin over alfuzosin, the Health Plans preferred alternative. The documentation does not support prior trial and failure of the preferred alternative. Hence, tamsulosin HCL 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 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: An enrollee has requested authorization and coverage for Zepatier for the treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1b patients should be treated with regimens including or Zepatier. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  For these reasons, Zepatier is medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested medication regimen 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for his Oncotype Dx Prostate Cancer Assay.  Findings:  Three physician reviewers found that while the Oncotype Dx Prostate Cancer Assay has the propensity to determine the risk of recurrence and sometimes change therapeutic intervention based on risk, there is currently a lack of well designed, controlled clinical trials to demonstrate an improvement in health outcomes based on its use.  The National Comprehensive Cancer Network guidelines lists Oncotype Dx for patients post biopsy for patients with very low risk and low risk prostate cancer who did not receive therapy and are candidates for surveillance or active therapy with a life expectancy of 10 years. This patients prostate cancer was not newly diagnosed and the initial Oncotype was done in 2013. This patients progression of the Gleason score over a period of three years from 6 to 7 was enough to demonstrate progression. Thus, the Oncotype Dx Prostate Cancer Assay provided did not add any additional information not provided by the clinical situation and was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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 reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: An enrollee has requested authorization and coverage for Zepatier for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1a. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including Zepatier when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier for 12 weeks for treatment of his hepatitis C virus. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. Furthermore, the patient has tested as immune for hepatitis B, eliminating concern for reactivation of hepatitis B during treatment.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication regimen 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 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 reimbursement and prospective authorization and coverage for residential treatment center services provided for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that according to the documentation submitted for review this patient could have been treated at a lower level of care. According to colleagues treatment at the PHP level of care is appropriate when meal supervision is needed without requirement for 24-hour supervision. PHP admission generally requires that patients be at or above minimally acceptable weight such as greater or equal to 80% of ideal body weight and maintain other evidence of medical stability. In this case, the patient was medically stable. Her laboratory work-up was unremarkable. Her sodium, potassium, chloride, liver function tests, and albumin were all within normal limits. The patient weighed 101 pounds. Her ideal body weight is 125 pounds. She was above 80% of her ideal body weight. She did not require 24-hour observation for any medical problems. The patient did not have any suicidal or homicidal ideation. The patient did not have any psychosis, hallucinations, or paranoia that would require 24-hour observation. The patient was motivated for treatment. In addition, the standard of care is to treat patients in the least restrictive environment possible. For the reasons provided, the patient could have been treated in a less restrictive environment. 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.