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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Contrave TAB.The enrollee has a history of obesity, class I, with a body mass index (BMI) of 30-34.9, papillary thyroid carcinoma and post-surgical hypothyroidism. Her weight increased from 158 pounds (BMI 29.01) to 172 pounds (BMI 31.55). While this weight gain could be attributed to her hypothyroidism, as lab results showed elevated TSH this was not currently the case. Lab results showed a TSH level of 0.57 (within the normal range of 0.40-4.50), and the provider documented the enrollee was euthyroid, and should continue on the current thyroid replacement regimen of levothyroxine. Despite the enrollees euthyroid state, records indicate her weight gain could not be controlled with a low carbohydrate diet and lifestyle modification. She was interested in medication to assist with her weight loss, and the provider prescribed Contrave. Review of the current literature on obesity management indicates pharmacotherapy for obesity can be considered for patients who have a body mass index (BMI) of 30kg/m2 or greater. Since this enrollees BMI is 31.55, refractory to lifestyle modifications, including diet and exercise, and her obesity is not the result of poorly controlled hypothyroidism, she is a good candidate for weight loss pharmacotherapy. The FDA-approved drugs for treating obesity include Naltrexone-bupropion. However, alternatives, such as amphetamine-dextroamphetamine and Armodafinil are not. Amphetamine-dextroamphetamine is a generic name for Adderall, which is a controlled substance, schedule II drug with a high potential for abuse. It is an amphetamine-based stimulant drug used to treat Attention Deficit Hyperactivity Disorder (ADHD) and narcolepsy. Armodafinil is an FDA-approved medication for the treatment of narcolepsy, obstructive sleep apnea/hypopnea, and shift work sleep disorder. This medication too, is not listed as one of the FDA-approved drugs for treating obesity. In a 2016 systematic review and meta-analysis study of the association of pharmacological treatments for obesity with weight loss and adverse events, the safety and efficacy of Contrave (Naltrexone-bupropion) was evaluated. Based on this study, when compared to placebo, Contrave was associated with achieving at least 5% weight loss at 52 weeks. While this study provides evidence for the safety and efficacy of Contrave for the treatment of obesity, there is no such study and support for the other alternative medications, including amphetamine-dextroamphetamine and Armodafinil. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in endocrinology, diabetes and metabolism 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for bilevel positive airway pressure (BiPAP) machine and its associated supplies. Applying the practice guidelines from the American Academy of Sleep Medicine (AASM), this patient meets the criteria to establish the medical necessity of the BiPAP and related accessories for treatment of her moderate obstructive sleep apnea (OSA). The AASM state that for appropriate and effective management of patients with OSA treated with positive airway pressure: (1) Treatment of OSA with PAP therapy should be based on a diagnosis of OSA established using objective sleep apnea testing. (2) Adequate follow-up, including troubleshooting and monitoring of objective efficacy and usage data to ensure adequate treatment and adherence, should occur following PAP therapy initiation and during treatment of OSA. The records provided for review document that this patient underwent objective sleep apnea testing, which demonstrated findings consistent with moderate OSA. In addition, the patient has followed up with her provider and has been compliant with BiPAP for treatment of her OSA. Furthermore, the provider documented that the patient has experienced benefit with use of the BiPAP machine. Given these findings, the BiPAP machine and its associated supplies were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the equipment at issue was and 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 expertise in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar Gel 80 u/mL subcutaneous injection twice a week for six months. Acthar Gel is U.S. Food and Drug Administration (FDA) approved for the treatment of nephrotic syndrome (NS). While Acthar Gel has not been widely studied in IgA nephropathy, there is evidence that it may be beneficial in some patients. Researchers found that Acthar gel may meet an important treatment needed in patients with treatment-resistant NS in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. This patient has over three grams of proteinuria and renal biopsy diagnosis supports the presence of glomerulonephritis. Given these findings, the requested Acthar Gel 80 u/mL subcutaneous injection twice a week for six months is medically necessary for treatment of this patient. 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 subspecialty certification in nephrology 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

A patients parent has requested authorization and coverage for IVIG Gamunex-C. This patient has failed multiple pharmacological and behavioral treatments considered standard therapy for PANS. He continues to exhibit severe disabling symptoms and a progressive course. Current clinical guidelines based on consensus statements and limited research, support the use of multiple immunomodulatory therapies in combination in severe and progressive cases. For patients with severe refractory cases that fail first-line therapy, immunoglobulin therapy in combination with other pharmacological agents is likely to result in better outcomes with fewer relapses. Given this support, the requested IVIG Gamunex-C 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 IVIG Gamunex-C is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation medicine and is actively practicing. Physician reviewers 2 and 3 are board certified in neurology with special qualification in child neurology 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: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for a subcutaneous implantable cardioverter.The submitted documentation supports that the requested subcutaneous implantable cardioverter is medically necessary for the patient. Guideline statements from the American College of Cardiology (ACC) in 2011 and the European Society of Cardiology (ESC) in 2014 provide guidance on risk stratification in these patients. More recent data from Freitas and colleagues showed a strong correlation with severity of fibrosis on MRI and sudden death, which would indicate a higher risk in this patient. Based on this data, the patient could benefit from an ICD implant. This patient has hypertrophic cardiomyopathy and severe fibrosis on cardiac MRI, and symptoms of chest pain have been noted. Other findings from noninvasive studies have shown that the patient has significant septal hypertrophy. Under these circumstances, given the patients young age and no apparent need for pacing, a subcutaneous ICD device is indicated. Therefore, the requested subcutaneous implantable cardioverter is medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested device 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 subspecialty certification in cardiovascular disease and clinical cardiac electrophysiology, 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 authorization and coverage for 24-hour catheter-based impedance pH monitoring. The requested 24-hour catheter-based impedance pH monitoring will be useful to evaluate this patients intraesophageal liquid and gas movements associated with GERD and her complaints of belching (Cho; Disney and Trudgill). Current data support 24-hour catheter-based impedance pH monitoring for patients who have failed PPI therapy and have symptoms of belching. Data suggest that excessive belching may accompany GERD, but in some cases, belching may induce GERD. Thus, the diagnosis needs to be ruled out in order to provide adequate treatment. In addition, pH testing can differentiate between gastric and supragastric belches. When belching is the predominant symptom, supragastric belching is the main cause. The physician reviewer found that Supragastric belching can be accurately assessed using intraluminal impedance techniques, such as the requested procedure (Koukias, et al.). For these reasons, 24-hour catheter-based impedance pH monitoring is medically necessary for the evaluation of this patients belching and GERD. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for facial feminization surgeries (CPT codes: 21138, 21139, 67900, 20680, 21121, 15828, 15839, and 21209). Facial feminization surgery is medically necessary for many transgender women to help alleviate the psychological distress they experience related to gender dysphoria. Moreover, the World Professional Association for Transgender Health (WPATH) supports facial feminization surgery in well-selected patients. WPATH noted that non-genital surgical procedures are oftentimes of greater practical significance in the patients daily life than reconstruction of the genitals. The guidelines further report that, these reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. The physician reviewer found that this patient meets the WPATH criteria for gender dysphoria and indication for facial feminization surgery based upon clinical documentation of persistent gender dysphoria related to the presence of masculine facial features. The providers noted that the patients distress related to her masculine features is likely to be alleviated with the requested facial feminization surgeries. She has already undergone vaginoplasty and feminizing mammoplasty. All told, the requested facial feminization surgeries (CPT codes: 21138, 21139, 67900, 20680, 21121, 15828, 15839, and 21209) are medically necessary for 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left shoe orthotics. Studies indicate that limb length discrepancies more than 2.0 cm are frequently problematic and hip and knee pathology is present in an increased number of patients with limb length discrepancies over 0.5 cm. In addition, low back problems are reportedly common on same side of the body as the shorter limb. Studies concluded that the evidence suggests that gait deviations may occur with leg length discrepancies of more than 1.0 cm, with greater impact seen as the discrepancy increases. This patient presents with a history of severe trauma to the left lower extremity resulting in left foot and leg deformity. She is status post multiple reconstructive procedures, including left foot and ankle fusion with heel reconstruction. She has a documented leg length discrepancy of 1.9 cm and comorbid knee pain. She reported the left shoe orthotics help to correct her leg length discrepancy and manage her pain. The records document that she has been utilizing a left shoe orthotic on a long-term basis with functional benefit. Current evidence based medical literature supports the utility of shoe orthotics to reduce pain, improve function, and mitigate other musculoskeletal conditions in patients with leg length discrepancy. Therefore, the requested left shoe orthotics are medically necessary.Final Result: The reviewer determined that the requested device 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for fertility preservation services including: office visit (10);ultrasound (10); estradiol (10); progesterone (3); guided egg retrieval (1);  ultrasound guidance of oocytes (1); oocyte ID from follicular fluid (1);culture/fertilize oocytes (1); ICSI more than 10 oocytes (1); sperm isolation; complex prep (1); blastocyst culture (1); assisted hatching (1); embryo biopsy (1); embryo cryopreservation (1); specimen handing (4); phlebotomy (10) were medically necessary for treatment of this patient. Chemotherapy is a gonadotoxic treatment that can result in infertility. For reproductive aged patients with newly diagnosed cancer, it is within the standard of care to counsel them about their options for preservation of fertility. When appropriate, patients may undergo preservation of ovarian hormone production. Providers should discuss the risk of treatment-induced infertility as well as possible interventions to preserve fertility and hormone production prior to initiating gonadotoxic therapy, as was done in this case. Established techniques for fertility preservation include cryopreservation of embryos and oocytes, which is associated with the greatest likelihood of successfully generating offspring. This patient was recently diagnosed with osteosarcoma. She is of childbearing age and her provider recommended fertility preservation prior to undergoing treatment. Given this support, the fertility preservation services including: office visit (10);ultrasound (10); estradiol (10); progesterone (3); guided egg retrieval (1); ultrasound guidance of oocytes (1); oocyte ID from follicular fluid (1); culture/fertilize oocytes (1); ICSI more than 10 oocytes (1); sperm isolation; complex prep (1); blastocyst culture (1); assisted hatching (1); embryo biopsy (1); embryo cryopreservation (1); specimen handing (4); phlebotomy (10) were medically necessary for treatment of this patient.   Final Result: The reviewer determined that the services at issue were 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 obstetrics and gynecology 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 Premarin 1.25 mg a day. Based on current recommendations from the North American Menopause Society (NAMS), estrogen replacement may be continued beyond age 65 with the proper monitoring and review of risks and benefits. The NAMS position statement notes that hormone therapy remains the most effective treatment for vasomotor symptoms (VMS) and the genitourinary syndrome of menopause (GSM) and has been shown to prevent bone loss and fracture. The documentation provided for review indicates that this patient requires immediate management and control of her blood pressure. Once under control with a systolic blood pressure under 150, the patient may be started on Premarin, but at a dose not higher than 0.625 mg per day. Given these findings, the requested Premarin 1.25 mg a day is not medically necessary for 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 subspecialty certification in diabetes, endocrinology and metabolism 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 patient has requested authorization and coverage for intravenous immunoglobulin injections every two weeks. Stiff person syndrome is a neurological disorder characterized by muscle rigidity primarily in the truncal muscles and is commonly associated with autoantibodies to the GAD 65 receptor. The pathophysiology of the disease is caused by the decreased level of the glutamic acid decarboxylase (GAD) activity due to an autoantibody against GAD that decreases the level of gamma-aminobutyric acid (GABA). Most patients require treatment with immunotherapy with intravenous immunoglobulins, oral or intravenous steroids. The records provided for review document that this patient has experienced significant clinical improvement with the use of IVIG. Treatment has reportedly yielded a 60-70% clinical improvement in the patients symptoms. Given this support, the requested intravenous immunoglobulin injections every two weeks are medically necessary for treatment of this patient. 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 neurology 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 patient has requested authorization and coverage for double mastectomy. A mastectomy, defined as the complete removal of the breast tissue, is a surgical option for patients diagnosed with breast cancer as well as a prophylaxis to reduce the risk of breast cancer in high-risk women, a study found that, prophylactic mastectomy generally occurs in two different patient populations: (1) high-risk women without breast cancer who undergo bilateral prophylactic mastectomy (BPM) to reduce their risk of developing breast cancer and (2) women with unilateral breast cancer who choose contralateral prophylactic mastectomy (CPM) to prevent cancer in the contralateral breast. Most studies conclude that BPM is not indicated for women without quantifiable high-risk demonstrated with a strong family history and/or findings on breast biopsy known to increase risk of future invasive cancer such as atypical hyperplasia or lobular carcinoma in situ. Alternative strategies for managing high-risk patients include rigorous surveillance with clinical breast examinations, mammography, and potentially breast MRI, endocrine therapy, and lifestyle changes. 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 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.