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

The enrollee has Hashimotos thyroiditis and has been treated with thyroid therapy in another country. She is requesting authorization and coverage for the requested medication, levothyroxine 50mcg every Monday through Thursday and levothyroxine 75mcg every Friday through Sunday. She is also requesting authorization and coverage for the requested medication, metformin 500 mg daily. She reports an abnormal ultrasound performed in this country, which showed an autoimmune thyroiditis with new focal changes in the left lobe. An ultrasound showed a left thyroid nodule, which was determined by an endocrinologist to be without concerning features or lymphadenopathy, with no indication for fine needle aspiration based on the size or appearance of the lesion. The enrollee also indicates she has been treated for over 30 years with metformin for insulin resistance and is requesting a prescription for metformin. She is having a problem with breast-feeding and milk production has decreased. The endocrinologist indicates endocrine society recommendations remain unchanged at this time and there is no indication for use of metformin in a diagnosis of polycystic ovarian syndrome unless frank diabetes mellitus or pre-diabetes mellitus, with high risk of progression to overt diabetes mellitus, is present. The medical literature indicates levothyroxine is prescribed for hypothyroidism as a replacement therapy in primary, secondary, and tertiary congenital or acquired hypothyroidism.  The record indicates the enrollees report of a diagnosis of thyroiditis and treatment for the past 15 years with thyroid therapy in her home country. The enrollees most recent thyroid function tests were normal. Therefore, it would not be appropriate to discontinue treatment as the two different doses of levothyroxine are keeping the enrollees levels at goal.  The medical literature indicates metformin is prescribed as an adjunct to diet and exercise to improve glycemic control in adults and children with a diagnosis of type two diabetes mellitus.  The record indicates the enrollee was previously diagnosed with glucose intolerance. She has utilized metformin for over 30 years. As the enrollee has utilized the medication with benefit and due to the enrollees glucose intolerance, the requested medication is appropriate.Final Result: The reviewer determined that the requested services are 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

The enrollee is requesting authorization and coverage for facial feminization surgeries.  She understands the surgical risks and benefits. The enrollee has experienced gender dysphoria for 20 years. Although these surgeries do not require a referral by mental health professionals, these professionals play an important role in assisting people with making a fully informed decision about the timing and implications of these procedures. Most of these procedures are generally labeled purely aesthetic, but for an individual with severe gender dysphoria they can be considered medically necessary, depending on the unique clinical situation of the individual. The records indicate the enrollee has the capacity to make a fully informed decision, did not have a significant medical health concern and there were no mental health concerns present. The enrollee is undergoing therapy, as needed and will continue to do so.  The records support the patients readiness to undergo the surgical intervention as she had been living as a woman and is comfortable as a woman.  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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an enrollee has requested authorization and coverage for Omnitrope. Based on medical literature, the records do not support a diagnosis of GH deficiency. The diagnosis of GH deficiency is supported by a GH stimulation test. The records do not document that the patient has undergone a GH stimulation test with results consistent with GH deficiency. Based on other documents, the patients growth velocity is 7 cm per year, without any GH treatment. This is a normal growth velocity and does not support a pathologic cause for short stature. There is no recent bone age prior to starting GH therapy to estimate the patients adult predicted height. The patients pre-treatment height in July 2019 was -1.85 standard deviations (SDs) below the mean. GH is indicated for idiopathic short statute when a patients height is below -2.25 SDs for age and gender. All told, Omnitrope was not and is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was not and 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 pediatrics with subspecialty certification in pediatric endocrinology 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 Pennsaid 2%. Topical analgesics may be beneficial for the treatment of pain in a superficial location after trial and failure of oral medications including non-steroidal anti-inflammatory drugs (NSAIDs). In this case, there is no documentation of trial and failure of oral NSAIDs. The provider noted that the patient was treated with Voltaren gel without improvement. Additionally, there are no diagnostic reports, documentation of pain intensity, or physical examination of the musculoskeletal system to support the request for Pennsaid 2% solution. All told, the requested Pennsaid 2% 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 rheumatology 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 panniculectomy surgery (CPT code 15830). The medical records do not include documentation of any supervised physician treatment of rashes, yeast infections, or bacterial infections underneath the pannus. The provider reported that the patient has a history of vaginal yeast infections treated with oral fluconazole. Based on the available records, there is insufficient evidence of recurrent rashes and infections unrelieved by conservative medical therapy directed at the fold underneath the pannus. Additionally, the photographs do not demonstrate a recurrent rash. There is also no documentation of any functional disability related to the abdominal pannus, and no documentation that the patient has maintained a stable weight. Given these findings, the requested panniculectomy surgery (CPT code 15830) is not medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. This patients condition does not constitute an abnormal structure of the body. The appearance of the body is normal for someone who has gained and lost a significant amount of weight. The requested surgery could be considered to improve function if there are documented rashes underneath the pannus causing functional issues with activities of daily living, and these rashes are not managed with conservative medical therapy. In this case, there is a lack of documentation of medically supervised treatment of the rashes. Although there is one note documenting the use of nystatin powder, there are no prescriptions noted for any antifungal medications or antibiotics to treat issues related to the pannus. Moreover, the records do not report any rashes that have persisted despite adequate therapy. Therefore, the requested panniculectomy surgery (CPT code 15830) is not reconstructive in nature.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld. 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: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for lap band removal surgery and gastric bypass revision surgery to be performed at the same time.The requested gastric bypass revision surgery is not supported in this clinical setting. There are no anatomic complications or improvements reported in the patients records to warrant any revision of the patients gastric bypass. Normal anatomy is documented and this cannot be removed. Further distalization of the gastric bypass is not a standard procedure and would be considered investigational at this time. Accordingly, gastric bypass revision surgery is not medically necessary to treat the patients medical condition.The submitted documentation supports the medical necessity of lap band removal surgery. The patient has epigastric pain that is secondary to the port of the lap band. This is a foreign body and it cannot be improved without surgical removal. The patient also has nausea, and this may also be related to the lap band. Lap band deflation would not impact the port, and if the patient is enduring chronic epigastric pain related to the port, it can only be corrected by removal. Lap band and port removal are reasonable and medically necessary, as medical treatment is not possible given that it is a foreign body. Under these circumstances, lap band removal surgery is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for transforaminal epidural steroid injections, Norco 10/325, and Flexeril, 10mg. The enrollee has low back and right leg pain. The enrollee received a right lumbar transforaminal block. She has chronic, disabling pain, which has caused psychological, social, and physical impairment. Conservative treatments have been used without relief. These include non-steroidal anti-inflammatory drugs and physical therapy. The record indicated her blood level of Norco was within normal limits and her urine toxicology screen was also normal, with no use of illicit substances. The enrollee indicates with her current pain medications, she was able to feel better, sleep more and be more active. She did not report any side effects related to the pain medication. The prescriber is requesting authorization for dexamethasone, 1mg injections, for nerve block. Limiting epidural steroid injections to four sessions per year is supported by clinical practice guidelines, but there is no limit on the number of years. The procedure is medically reasonable and necessary. This enrollee indicates she is able to sleep more and be more active.  The record shows meaningful improvement in pain and function.  A regulatory body approved Norco for the relief of moderate to moderately severe pain. A professional society indicates persons with over 90 days of opioid therapy should have documentation of urine drug testing for adherence monitoring in order to decrease prescription drug abuse or illicit drug use.  The enrollee was being monitored through the controlled substance utilization review and evaluation reporting system.  The records indicated there was a pain agreement on file and the enrollee had no aberrant behavior. Although there was a lack of documentation indicating the enrollee had been placed into one of three risk categories, the enrollee was being monitored appropriately. There is no indication of any abuse or diversion.  The requested medication is medically reasonable and necessary. Pharmacologic intervention for pain management is the principal treatment modality for pain, even though adverse drug reactions in the elderly are a significant risk. The manufacturer does not recommend the use of Flexeril for periods longer than two or three weeks. Current literature does not support a direct analgesic effect of these drugs. The use of muscle relaxants beyond one month is an off-label use and not supported by clinical evidence.Final Result: The reviewer determined that the requested services are partially medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in anesthesiology and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for right hip replacement surgery. The enrollee has a medical history of hypertension and osteoarthritis of the right hip and was seen by an orthopedic surgeon for right hip pain. At a visit several years later with a different orthopedist, the enrollee complained of right hip pain which began several years prior and has continued despite conservative management, which has included weight loss, oral non-steroidal anti-inflammatory drugs, bracing, physical therapy, and injections. He is unable to perform activities of daily living without pain. An x-ray of the affected hip showed degenerative changes including joint space narrowing, subchondral sclerosis, and osteophyte formation.  The enrollee was told to stop smoking. Right hip replacement was discussed after which the enrollee indicated he wanted to proceed with the surgeryThe enrollee indicated he was unable to proceed with the surgery because he was a former smoker and still uses nicotine gum and spray. His pain medication was changed to hydrocodone-acetaminophen and he was advised to stop using nicotine replacement if that is what was advised by the orthopedist. This enrollees physical examination revealed the right hip had a range of motion from 10-90 degrees, with zero degrees internal rotation and 20 degrees external rotation.  There was positive impingement. The enrollee was advised to undergo a pre-operative appointment and to follow up in two weeks.  The surgeon did not want to perform the procedure due to the enrollees inability to discontinue smoking.  The enrollee detailed he was vaping. However, the most recent notes indicate he has been utilizing nicotine gum and spray.  Therefore, it does appear the enrollee has attempted smoking cessation. Given the enrollee's clinical picture, it does not appear any other treatment will provide benefit.  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 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for perirectal spacers. The National Comprehensive Cancer Network (NCCN) guidelines recommend prostate localization using image guided radiation therapy (IGRT) with either three-dimensional conformal radiation therapy (3D-CRT) or intensity modulated radiation therapy (IMRT) for target margin reduction and treatment accuracy. The guidelines do not recommend on use of perirectal spacers, such as the SpaceOAR system, for prevention of rectal complications. Similarly, the American Urological Association (AUA) do not comment on the use of perirectal spacers to be used during IMRT or IGRT. Therefore, the perirectal spacers were not 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 that the perirectal spacers were 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 medical device 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, and 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for BRCA1 and BRCA2 genetic tests (CPT codes: 81408, 81479, 96040, 81162, 81211, and 81213). While there is benefit in BRCA2 testing in males at risk for cancer, a full genetic work-up is not consistent with the current recommendations. This patient has no known personal risk of cancer. His mother has a history of cancer with a BRCA2 mutation. Given the presence of a specific genetic mutation in his family, testing of the specific mutation identified in his mother is appropriate. Males with BRCA2 mutations are known to have increased risk of breast cancer and prostate cancer. Identification of a BRCA2 mutation in this patient would lead to increased screening or higher index of suspicion should symptoms develop. The records do not support full panel genetic testing as requested. The patient has been approved for BRCA2 testing (CPT code 81217). Thus, the BRCA1 and BRCA2 genetic tests (CPT codes: 81408, 81479, 96040, 81162, 81211, and 81213) are not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the BRCA1 and BRCA2 genetic tests (CPT codes: 81408, 81479, 96040, 81162, 81211, and 81213) are not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 genetics 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

The patient has requested reimbursement for residential treatment center (RTC) services. Applying LOCUS, the patient met the criteria for RTC services. The patient presented with some risk of harm, given the lack of suicidal ideation or safety concerns. However, the records document issues of self-neglect as a result of his obsessive compulsive disorder (OCD) behaviors. The patient demonstrated severely impaired functional impairment. The patient has not been able to participate in school or work and has no social relationships. The records document a history of comorbid ADHD. The patients recovery environment was mildly stressful. He had no supports outside of his father. The patients recovery environment was supportive. He had an outpatient therapist. The provider noted that there were no community-based services for OCD available. The patient demonstrated limited improvement with treatment due to his severely refractory OCD. He has failed outpatient treatment as well as several medications trials and RTC admissions. However, based on his score for functional status, he met the criteria for medically monitored residential services. Moreover, RTC has been found to have improved outcomes for patients with severely refractory OCD. All told, the RTC services received 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 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.