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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400-100 mg tablets for 12 weeks 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 medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage. The guidelines recommend several medications, but Epclusa is the most appropriate therapy in this case based on NS5A resistance testing. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  Final Result: The reviewers 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 number is a 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 Epclusa for 12 weeks. 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 should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. The guidelines state that all patients should be treated, regardless of fibrosis stage, and advanced fibrosis is not a requirement for treatment.  Additionally, the patient should be considered treatment-naive per the guidelines, as he failed interferon, rather than PEG-interferon with ribavirin.  Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment-naive, genotype 3 patients. The current guidelines cite data showing reduced survival with delayed treatment. For these reasons, Epclusa for 12 weeks is medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the 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 Harvoni 90 mg - 400 mg treatment of the his 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 or those who have failed PEG-interferon and ribavirin should be treated with Harvoni for 12 weeks, Epclusa for 12 weeks, or Zepatier for 12 weeks, and the medications are U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage. No medical contraindication to Zepatier or Epclusa is reported in this case. For these reasons, although treatment of hepatitis C is needed, the requested treatment with Harvoni is not medically necessary over Zepatier or Epclusa for the treatment of this patients hepatitis C infection. Final Result: The reviewers 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Standard Review: A transgender male enrollee has requested authorization and coverage for consultation with a plastic surgeon regarding a bilateral mastectomy. The Health Plan has denied this request indicating that the requested services are not medically necessary for the evaluation 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: Based on the documentation provided, the patient has documented gender dysphoria and is in the process of transitioning to the male gender. According to the records provided, this patient has lived as a male for many years. While he has been undergoing prescribed hormonal therapy for more than 3 years, he has evidence of breast development that is abnormal for a male gender. The records provided also indicate that he continues to have gender dysphoria related to breast development. The records note that he binds his breasts regularly.  In addition, his treating providers noted that this patient is ready for a breast mastectomy and support his request for consultation. Based on the patients gender dysphoria and identification as a male, a normal appearance of the breasts for a male should be the goal. All told, there is sufficient documentation to maintain next steps towards this patients transition to the male gender. Therefore, a consultation with a plastic surgeon regarding a bilateral mastectomy is medically necessary for the evaluation of this patients gender dysphoria. Final Result: The reviewer determined that the requested services are medically necessary for the evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
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 and nipple/areola reconstruction. 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 documentation provided supports the requested services in this clinical setting. Based on the documentation provided, the patient has gender identity disorder and is transitioning to the male gender. This patient has female breasts that would not likely resolve with continued hormonal therapy. While the Health Plan criteria provides that the patient should be 18 prior to undergoing surgical intervention, chronological age is not as important as the level of pubertal development. In this patients case, his breasts appear to be consistent with a teenage 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.  All told, 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 and nipple/areola reconstruction are 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. As such, the abnormal breasts is 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. In sum, bilateral mastectomy and nipple/areola reconstruction are reconstructive in nature. Final Result: The reviewer determined that he requested services are medically necessary and are 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: An enrollee has requested authorization and coverage for testing for mycotoxin illness, candida albicans antibodies, leptin, melanocyte stimulating hormone, human transforming growth factor beta 1 vascular endothelial growth factor (VEGF), vasoactive intestinal peptide, matrix metallopeptidase 9 (MMP-9), complement C3 and C4, antidiuretic hormone (ADH), and allergen profile (mold) for evaluation of her reported mold related illness. Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting. Based on the medical literature reviewed, the patient requested panel of immune laboratory tests which are not considered clinically useful, relevant, or a valid method of screening for mold related (mycotoxin) illness. The practice of performing large numbers of nonspecific immune based tests as an indication of mold exposure or mold related illness is not evidence-based and are discouraged. Exposure to molds and their products does not induce a state of immune dysregulation. Testing to determine the presence of immunoglobulin E (IgE) to specific fungi might be a useful component of a complete clinical evaluation in the diagnosis of allergic illnesses (e.g., rhinitis and asthma) that can be caused by immediate hypersensitivity.  Moreover, the health effects from inhalational exposures to mold toxins are not well documented.  The literature does not support that exposure to molds and their products induce a state of immune dysregulation (e.g., immunodeficiency or autoimmunity). Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in allergy and immunology 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 Vemlidy 25 mg daily for eight weeks for treatment of her chronic hepatitis B virus. Findings:  The physician reviewer found that guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. The records note that Entecavir has failed in treatment of this patient due to suspected resistance. In comparison with tenofovir disoproxil fumarate (Viread), which the patient takes, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with fewer side effects, including osteopenia and renal disease. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for daily Klonopin 1 mg, two pills in the morning and Klonopin 1 mg, 1.5 pills in the evening for treatment of her posttraumatic stress disorder and attention deficit hyperactivity disorder.  Findings:  The physician reviewer found that this transgender female is diagnosed with bipolar disorder, depression, severe without psychotic features, posttraumatic stress disorder, anxiety, and attention deficit hyperactivity disorder. The patient suffers from insomnia and reportedly neurocognitive difficulties. The provider notes cluster B traits. Her medical diagnoses include peptic ulcer disease, cardiac arrhythmias, and migraines.  She showed multidimensional hallucinations, and reported nightmares and flashbacks.  It was at that time that she was placed on Klonopin 1 mg two per day (BID).  Since this time, she has been on Risperdal, Ativan, and trazodone. Latuda was added later. It is unclear when this was discontinued.  She was on Adderall which was subsequently changed to Concerta.  She was on Trileptal, which was discontinued, and she reported feeling more alert. Klonopin was reduced to 1 pill in the morning and 2 pills in the evening.  Buspar was added.  The patient reported low energy and feeling down. Her mood was positive, she presented as well-groomed and stylish.  She noted that she has fractionally reduced the hydroxyzine and Klonopin. The patient has requested coverage for daily Klonopin 1 mg, two pills in the morning and Klonopin 1 mg, 1.5 pills in the evening. The patients documentation does not support the requested increase of Klonopin dosing. Symptoms reported do not support the need for coverage of 3 12 tablets per day (3 12 mg a day). The provider does not show documentation that the dose was increasing by small amounts to manage symptoms or decrease side effects/slowly wean off.  Moreover, there was no evidence that the patient was a rapid metabolizer and therefore required a higher dose of this agent.  The requested increase of Klonopin is not supported by the submitted records. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Stelara (ustekinumab) 90 mg/mL injection every 12 weeks. Findings:  The physician reviewer found that the records document extensive, recalcitrant psoriasis.  He has tried and failed therapy with topical steroids, methotrexate, Enbrel and Humira. The patient was previously treated with Stelara 90 mg/mL injections, with excellent effect.  The patient has tried treatment with Stelara 45 mg/mL injections, and this has not maintained clearance. The medical evidence supports the requested medication dosage in this patients case.  The patient has already shown response to the requested dose and lack of response to the typical dose. Final Result: The reviewer determined that the requested medication dosage 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 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: an enrollee has requested authorization and coverage for Repatha 140 mg. Findings:  The physician reviewer found that this patient has documented obstructive atherosclerotic vascular disease, elevated low-density lipoprotein cholesterol level despite use of Zetia medication, and documented intolerance to several statin medications. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic vascular disease who require additional lowering of low-density lipoprotein cholesterol. This patient fits the latter criteria.  In this setting, the use of PCSK9 inhibitors such as Repatha has been demonstrated in randomized trials to both lower cholesterol and reduce adverse cardiac outcomes in post hoc analyses. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 172 hours per month of direct applied behavioral analysis (ABA) therapy and 22.5 hours per month of supervision for treatment of her autism. Findings:  The physician reviewer found that the request for 172 hours per month of direct ABA therapy and 22.5 hours per month of supervision is medically necessary for treatment of the patients autism. Research has demonstrated increased progress towards learning objectives with increased intensity of treatment for children with autism. In this case, the patient demonstrates problematic behaviors which include aggression, tantrum, motor stereotypy, mouthing, visual stereotypy and inappropriate touching. The patients inability to master these skills puts her at an increased risk for injury, and also makes it difficult to be successful in more generalized environments. Based on the clinical documentation provided for review, the requested services are medically necessary for treatment of the patients medical condition. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 female enrollee has requested reimbursement for the FlexHD provided.  Findings:  The physician reviewer found that there is a paucity of research on the use of a dermal allograft in anterior repairs. The use of FlexHD is not approved by the U.S. Food and Drug Administration (FDA) to be used as a vaginal graft material. Moreover, there is a lack of evidence that this graft would have any better outcomes than using a porcine graft or polyglactin absorbable graft. This allograft material has been used in dental surgery, breast reconstruction and abdominoplasty. However, there is inadequate data demonstrating an advantage of using the FlexHD over other absorbable graft materials for anterior repairs. Based on the foregoing discussion, the FlexHD used was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was 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 & 3 are board certified in urology 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.