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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for facial feminization surgery performed on 6/25/20. Findings:  The physician reviewer found that facial feminization surgery relieves gender dysphoria through harmonization with regard to other modified structures...achieving an aesthetic result beyond gender difference. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, improved mental health-related quality of life. The World Professional Association for Transgender Healths (WPATH) Position Statement on Medical Necessity of Treatment noted that non-genital surgical procedures, including facial feminization surgery, is often of greater practical significance in the patients daily life than reconstruction of the genitals. WPATH noted, These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. In this case, the patient has been diagnosed with gender dysphoria and, as a result, had symptoms of chronic anxiety, depression, low self-esteem, agoraphobia, and overall severe distress. The medical evidence supports the services at issue in this clinical setting. Therefore, facial feminization surgery performed on 6/25/20 was medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the service at issue was 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for U.S. Food and Drug Administration (FDA) approved noninvasive laminotomy/laminectomy, foraminotomy/foraminectomy, and discectomy (LFD) and disc replacement. Findings:  The physician reviewer found that Srinivas and colleagues noted that alleviation of clinically significant low back pain after lumbar decompression surgery for neurogenic claudication was observed at three, 12, and 24 months in the majority of patients treated. Held and colleagues concluded that there is strong evidence that surgical treatment is superior to nonoperative treatment for elderly patients with degenerative lumbar spinal stenosis. Wang and colleagues reported that concomitant degenerative spondylolisthesis does not influence the outcome of decompression alone in degenerative lumbar spinal stenosis, especially when a minimally invasive procedure was performed, and patients did not have predominant symptoms of mechanical back pain. The presence of degenerative spondylolisthesis is not considered an indication for surgery in degenerative lumbar spinal stenosis. The FDA approval for the ProDisc-L total disc replacement states that this device is indicated for patients with degenerative disc disease at one level in the lumbar spine from L3 to S1 with no more than grade 1 spondylolisthesis at the involved level and symptoms that have persisted despite at least six months of non-surgical treatment (Zigler and Delamarter). The records provided for review document that this patient is being treated for lumbosacral disc degeneration and lumbar spondylosis. Progress notes indicate a greater than 20-year history of low back pain. The pain is noted to be mainly axial, localizing to the waist with occasional radiation into the buttocks and hips, and left thigh and heel. Detailed documentation is not evident regarding specific objective findings corroborating nerve root compression to support the requested decompression procedures. The patients magnetic resonance imaging (MRI) revealed multilevel significant degenerative disc disease and stenosis. In this clinical setting of multiple possible significant pain generators, there is a lack of a specific indication for disc replacement. Therefore, the requested FDA approved noninvasive LFD and disc replacement 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Myriad myRisk Genetic Panel. Findings:  The physician reviewer found that The records provided for review document that this patient has a history of stage IA invasive ductal carcinoma of the left breast status post lumpectomy. Pathology revealed estrogen receptor (ER), progesterone receptor (PR) positive, and human epidermal growth factor receptor 2 (HER-2) negative. The patient underwent testing with Oncotype Dx to help assess her treatment options. Her provider has recommended further analysis with the Myriad myRisk genetic panel. The myRisk panel is a comprehensive panel that tests for germline mutations in genes that predispose a patient to cancer. The myRisk panel is indicated for patients when a familial predisposition syndrome is not well characterized based on history, as in this patients case, when both BRCA and Lynch syndrome genes may be implicated. A BRCA1 mutation can increase the patients risk for breast, ovarian, cervical, uterine, pancreatic, and gastric cancers. BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, pancreatic, and gastric cancers. In the event the BRCA tests are negative, there is still a possibility of hereditary predisposition from another gene defect. According to the National Comprehensive Cancer Network (NCCN) guidelines, the testing criteria for high penetrance of breast and ovarian cancer susceptibility genes includes BRCA1 and BRCA2, CDH 1, PALB 2, PTEN, and TP53. NCCN includes a comprehensive gene lists for testing that is supported by the current medical evidence. Given this support, the requested Myriad myRisk Genetic Panel is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Myriad myRisk Genetic Panel is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation 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 medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications medical oncology and hematology 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: The patients parent has requested authorization and coverage for two one-hour speech therapy sessions per week consisting of oral motor intervention using Beckman Oral Motor techniques. Williams syndrome is caused by a deletion of part of chromosome 7. children with Williams syndrome to have a unique cognitive and behavioral profile. The authors noted that, Children demonstrate a relative strength in language and verbal short-term memory, with a significant weakness in visuospatial construction.  the core difficulties associated with Williams syndrome have a cascading effect on many areas of development over time. Thus, speech therapy is medically necessary for this patient to address her impaired pragmatic language, and low tone and muscle weakness. The records document that the patients provider has utilized an approach referred to as the Beckman Oral Motor Protocol. Although there is limited peer-reviewed medical literature available specifically addressing Beckman Protocol, this is only part of the speech therapy that is being provided by the patients provider. The patient meets the criteria for oral motor therapy, and Beckman Protocol is one form of this therapy. Given the patients progress with this providers treatment regimen, the Beckman Protocol and therapy focusing on pragmatic speech as provided by the therapist are appropriate for this patient. The requested services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and are not primarily for the convenience of the patient or provider. For these reasons, the requested two one-hour speech therapy sessions per week consisting of oral motor intervention using Beckman Oral Motor techniques 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. Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a connective tissue implant, nonhuman (including synthetic). Findings:  The physician reviewer found that there is a lack of data in current medical literature demonstrating the effectiveness of various biologic patches to augment the repair of large or complex rotator cuff tears. Micheloni and colleagues report that while the use of bioinductive implants could represent an effective aid in arthroscopic rotator cuff repair in selected cases and with the correct indications,  no current scientific evidence regarding such implants existed. In this case, an operative report reported that the patient underwent left shoulder arthroscopy for treatment of a massive rotator cuff tear involving the supraspinatus. In this clinical setting, there is a lack of data showing that the service at issue was an effective and/or safe treatment for the noted pathology, and the submitted documentation did not include compelling rationale or extenuating circumstances supporting the use of the service at issue. Therefore, the connective tissue implant, nonhuman (including synthetic) (CPT C1763) was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the connective tissue implant, nonhuman (including synthetic) (CPT C1763) at issue was not likely to have been 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 have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of a hypoglossal nerve stimulator (Inspire Upper Airway Stimulation System). The records provided for review document that this patient has obstructive sleep apnea (OSA) with an apnea/hypopnea index (AHI) of 32.4. The drug induced sleep endoscopy (DISE) showed no concentric collapse at velum and primarily anterior posterior collapse. The patient has been unable to tolerate treatment with continuous positive airway pressure (CPAP) device. The patients provider has recommended treatment with the Inspire device, which is a U.S. Food and Drug Administration (FDA) approved device for the treatment of OSA device. Based on the available documentation, the patient is a candidate for the Inspire device given her intolerance to CPAP and lack of effectiveness of an oral appliance, primarily anterior posterior collapse, and minimal central apnea. Moreover, the patients apnea/hypopnea index (AHI) of 32.4 events per hour and reported body mass index (BMI) of 27.9 kg/m2 meet the FDA criteria for hypoglossal nerve stimulation with the Inspire System. Given these findings, the requested implantation of a hypoglossal nerve stimulator (Inspire Upper Airway Stimulation System) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested implantation of a hypoglossal nerve stimulator (Inspire Upper Airway Stimulation System) 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 services are 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 otolaryngology and is actively practicing. Physician reviewer 2 is board certified in otolaryngology and is actively practicing. Physician reviewer 3 is board certified in otolaryngology with subspecialty certification in sleep medicine 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: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS). TMS is indicated for the treatment of patients in the acute phase of major depression. Given that this patient is still experiencing symptoms of major depressive disorder, the requested treatment of TMS meets the criteria for medical necessity. The patients Personal Health Questionnaire 9 (PHQ-9) scores have historically indicated that he experienced some improvement in depressive symptomatology during the course of TMS. However, he still reports symptoms of major depression, which supports additional TMS sessions. The patient waited a 90-day period before requesting additional repetitive TMS sessions. Given the persistence of his symptoms, the requested TMS is considered part of a prolonged initial treatment phase. Moreover, TMS is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the requested TMS is 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. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xanax 2 mg, 1 tablet every 8 hours, not to exceed 6 mg per day, 90 tablets per month. In this case, the records indicate that the patients primary medical diagnosis is lumbosacral disc disease, with refractory back pain. Given the patients upcoming revision of lumbar fusion, pain medication may become a priority for the patients ability to function and maintain a quality of life. The combination of opioids with a benzodiazepine is contraindicated. Additionally, the requested dosage of Xanax is above what is recommended by the U.S. Food and Drug Administration (FDA). The FDA notes a maximum daily dose of 4 mg for the treatment of patients with anxiety. In this case, the records note that the patient is on a starting dosage of sertraline. It is likely that with an appropriate titration of sertraline, the patient will not require the requested dosage of Xanax. Given that benzodiazepines are not indicated for the long-term treatment of depression or anxiety, the requested medication is not medically indicated. In this patients case, Xanax 2 mg, 1 tablet every 8 hours, not to exceed 6 mg per day, 90 tablets per month is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested medication is not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested medication is primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, Xanax 2 mg, 1 tablet every 8 hours, not to exceed 6 mg per day, 90 tablets per month 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 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: The patient has requested authorization and coverage for Percocet 10 mg/325 mg, one tablet every four hours, #180 per month. The Centers for Disease Control and Prevention (CDC) guidelines state that when opioid therapy is used, a patients regimen should include nonpharmacologic therapy and nonopioid pharmacologic interventions. Additionally, the CDC noted that, Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The American Society of Interventional Pain Physicians (ASIPP) guidelines recommend providers to establish physical diagnosis and assess pain levels and disability to support medical necessity of treatment with opioids. In this case, the patient has chronic low back pain due to lumbar radiculopathy with recent increased pain and disability due to complications related to pain pump implantation. She is scheduled for hardware revision of the lumbar spine. The records document that the patient has tried and failed all forms of conservative therapy as well as advance pain management procedures including spinal cord stimulators and pain pumps. The providers notes state that the patient has not shown any aberrant or drug seeking behavior. Treatment with Percocet has enabled the patient to perform of activities of daily living. In addition, the provider reported that there is no evidence of adverse drug reactions or aberrant behavior identified. The providers documentation is consistent with the guidelines from the CDC and ASIPP for the safe prescribing of opioid therapy. Given this support, the requested Percocet 10 mg/325 mg, one tablet every four hours, #180 per month 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 anesthesiology with subspecialty certification in pain management 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.