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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for testosterone cypionate 200 mg injection every seven (7) days. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients testicular dysfunction. The submitted documentation supports the medical necessity of the requested medication regimen. Low testosterone can lead to such complications as reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue. For these reasons, many providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dL. The general target level for testosterone ranges from 350 to 750 ng/dL, which is roughly the range for healthy, androgen-sufficient adult men. Testosterone levels should be monitored every three to six months after initiation of treatment in order to assure that the patients testosterone level is optimal, and the dose of testosterone replacement therapy should be adjusted accordingly. Therefore, the requested testosterone cypionate 200 mg injection every seven (7) days is medically necessary for 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A transgender enrollee has requested authorization and coverage for facial feminization surgeries including brow lift, frontal bone contouring, genioplasty, autologous fat grafting, and tracheal shave. Gender dysphoria refers to distress that is caused by a discrepancy between a persons gender identity and that persons sex assigned at birth. This often results in depression and anxiety. Treatment for gender dysphoria aims to minimize dysphoria and help patients attain their sought-after gender role. A paper notes that facial feminization procedures are not cosmetic, but rather serve a primarily reconstructive purpose in transgender women whose overall physical appearance otherwise prevents them from being perceived as female. The statement from  multiple organizations including the American Medical Association, American Association of Family Physicians, Endocrine Society, American Psychiatric Association, American Psychological Association, American College of Obstetricians and Gynecologists, and the American Public Health Association notes that the medical procedures attendant to sex reassignment are not cosmetic or elective or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. A publication notes that gender reassignment is the only treatment for gender dysphoria that has shown significant benefits in numerous research trials and meta-analyses over the past half century. A study concludes that Transwomen have diminished mental health-related quality of life compared with the general female population. However, surgical treatments (e.g. FFS [facial feminization surgery], GRS [gender reassignment surgery] or both) are associated with improved mental health-related quality of life  Further a paper notes that this surgery does not aim to rejuvenate the face but rather it helps transgender women in passing as a female and integrating into everyday society. In conclusion, the submitted documentation demonstrates the patient experiences significant anxiety and distress secondary to her male facial features. There is sufficient scientific literature demonstrating that facial feminization surgery is effective in relieving gender dysphoria in patients such as this patient. Therefore, 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 psychiatry with expertise in treatment of gender dysphoria 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 hydrocortisone valerate cream. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees lichen planus. The submitted documentation does not support the medical necessity of the requested medication. This enrollee has had a trial of hydrocortisone valerate cream with some improvement. The enrollee has not tried and failed the preferred formulary agents, including mometasone cream/ointment/solution, triamcinolone, and cream/ointment/lotion. It is reasonable that the enrollee use the preferred agents for treatment of the enrollees lichen planus, as there are preferred topical steroids of the same potency class as hydrocortisone valerate. Therefore, hydrocortisone valerate cream is not medically necessary for the treatment of this enrollee.Final Result: The reviewer determined that the requested  medication is not medically necessary for treatment of the enrollees 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the FoundationOne genomic analysis. Molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered within the standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) guidelines advises broader molecular profiling with the goal of identifying rare driver mutations for which effective medications may be available, or to appropriately counsel patients regarding the availability of clinical trials. Thus, the FoundationOne genomic analysis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the FoundationOne genomic analysis was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  All three 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: A enrollee has requested authorization and coverage for Januvia 100 mg. Januvia and Tradjenta are members of the same class and are considered equally effective barring any renal or hepatic function impairment. Thus, these two medications are substituted for one another. This patients records do not include documentation from the patients provider that one medication has been more effective than the other. In addition, there is no evidence that the patients diet and exercise and weight were the same while being treated with both medications. Thus, there is a lack of documentation to support the use of Januvia in lieu of Tradjenta. Accordingly, the requested Januvia 100 mg is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for trametinib dimethyl sulfoxide (Mekinist) tablets. Findings:  The physician reviewer found that Mekinist has been approved for use, either alone, or with Tafinlar, in patients with melanoma that is BRAF mutation positive. There has also been benefit in patients with non-small cell lung cancer and thyroid cancer. However, there is a paucity of data on the use of Mekinist in an adenocarcinoma of the parotid. Overall, the use of mutations to guide therapy remains controversial. In addition, this patients multi-gene assay report that identified the tumor as HRAS positive did not recommend Mekinist therapy. For these reasons, the requested trametinib dimethyl sulfoxide (Mekinist) tablets daily is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested medication is 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  All three 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 Orthovisc injections. There is sufficient support for the requested services in this clinical setting. The current literature supports the use of viscosupplementation for osteoarthritis of the knee. Campbell and colleagues performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. The authors noted that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis. This patient has pain due to osteoarthritis and has benefitted from prior viscosupplementation. Therefore, the requested Orthovisc injections are medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The patients post-acute withdrawal symptoms were described as mild consisting of muscle aches. The patient has not been suicidal, homicidal, aggressive, or violent. The patient has been cognitively intact and not gravely disabled. There have been no emotional, behavioral, cognitive, or impulsive symptoms that would warrant the RTC level of care. The patient has been medically and psychiatrically stable to the extent that they do not require  24-hour a day continuous monitoring. The patient's medication management and Suboxone treatment can be safely provided in an ambulatory setting, which is considered the standard of care in the community. Although described as having impulse control difficulties, there has been no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom severe enough that would interfere with their care. The patient has been motivated, cooperative, and engaged. The patient is described as participating in all aspects of their treatment plan and treatment modalities. The patient has struggled with emotions, but further treatment to help develop coping skills does not require the structured environment of a RTC setting. The patient could have been stepped down to an ambulatory level of care such as partial hospitalization program (PHP). Given these findings, the RTC services were not and are not medically necessary for treatment of this patients behavioral health condition. 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 with sub-specialty certification in addiction 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: An enrollee has requested authorization and coverage for lumbar facet joint injections. There is sufficient support for the requested services in this patients case. Before performing radiofrequency ablation of the medial branch, a dual set of diagnostic blocks are required, both of which must produce 80% or better pain relief for the expected length of the local anesthetic. In this patients case, one set of blocks produced 90% pain relief.  Therefore, a second set is medically reasonable. The medical evidence supports the requested services in this clinical setting. Therefore, the requested lumbar facet joint injections are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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: An enrollee has requested authorization and coverage for Prevpac combo pack. The submitted documentation fails to demonstrate the medical necessity of the requested medication. In this case, there is a lack of support for the use of the Prevpac brand formulation rather than the formulary alternatives, which are the generic form of the same medications (lansoprazole, clarithromycin, amoxicillin). The generic alternatives have proven effective when taken as separate tablets and capsules, and are supported by American College of Gastroenterology guidelines for the treatment of Helicobacter pylori infection. For these reasons, Prevpac combo pack is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma assay. The prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may add to these statistics. DecisionDx-Melanoma assay is a study of 31 genes in an individuals melanoma cells. It then classifies that melanoma as either class 1 or class 2, representing the individual risk of metastasis. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients who had undergone sentinel node sampling. However, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not clear if the DecisionDx-Melanoma classification can be used to make clinical decisions. Therefore, the superior efficacy of DecisionDx-Melanoma assay has not been established. Final Result: The reviewers determined that the services at issue were 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services.  This patient presented with neck pain radiating into the left upper extremity with associated numbness. The records documented a progression of symptoms to include pain radiating into the bilateral upper extremities and onset of lower extremity pain. The patient was referred for an in-network spine surgeon and was seen in consultation. The patient was also evaluated by an out-of-network spine surgeon. Clinical examination findings were consistent with imaging evidence of disc pathology with severe stenosis at C5-6 and C6-7 and electrodiagnostic evidence of acute C6 and C7 radiculopathy. There was no imaging evidence of cord signal change. Both providers recommended two-level anterior cervical discectomy and artificial disc replacement. The records documented that the patient proceeded with anterior cervical discectomy and artificial disc replacement at C5-6 and C6-7 with the out-of-network provider. There is evidence that the patient presented with a frank progressive neurologic emergency between the initial examination and surgery to support this as an emergent surgery, as defined by California law. The services at issue were necessary for treatment of an emergency medical condition. Thus, the patient received emergency medical services on the date(s) of service at issue.Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. 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.