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

Nature of Statutory Criteria/ Case Summary: The parent of the enrollee has requested authorization and coverage for monthly Privigen (intravenous immune globulin) infusion therapy. The enrollee is diagnosed with selective immunoglobulin G (IgG) subclass deficiency, which his physician states is a primary immune disorder, and  Pediatric Acute-onset Neuropsychiatric Syndrome (PANS). Laboratory results revealed elevated assay markers for Ca/Calmodulin Protein Kinase II, and borderline assay markers for Anti-Dopamine receptor D-1 and anti-Tubulin. Laboratory results showed a low IgG level. The enrollees physician states that it is medically necessary for him to receive intravenous immunoglobulin (IVIG) therapy to maximize his protection against infection and without IVIG he remains at high risk for life threatening infections. The medical literature supports Privigen for the treatment of primary humoral immunodeficiency (PI), chronic immune thrombocytopenic purpura (ITP) in enrollees age 15 years and older and chronic inflammatory demyelinating polyneuropathy (CIDP) in adults. IVIG has been described in multiple case reports and case series. Results from a self-reported survey study provide some support for IVIG being perceived as an effective treatment for PANS.  IVIG has been tested in two double-blind trials, with the higher quality study indicating low support.  Therefore, the evidence for using IVIG is inconclusive and does not substantiate IVIG as an appropriate treatment as further studies are needed to support efficacy and appropriateness. Final Result: The reviewer determined that the requested therapy was not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pediatrics and neurology with special qualifications 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 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 a WalkAide foot drop system.The requested WalkAide foot drop system is not medically necessary for treatment of this patients medical condition. Additional prospective clinical studies of the WalkAide device are necessary to evaluate whether it improves function and reduces disability compared to standard bracing in persons with foot drop (Miller, et al.; and Everaert, et al.).In this case, the WalkAide foot drop system has been requested to treat a patient with foot drop after a cerebrovascular accident. There is currently insufficient evidence to support the use of the requested WalkAide device for foot drop and other indications. Accordingly, the requested WalkAide foot drop system is not medically necessary for treatment of the patient's medical condition at this time.Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation, with subspecialty certification in neuromuscular 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

ature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continued applied behavioral analysis (ABA) services, including 22.5 hours per week of direct behavior technician, six (6) hours per month of direct supervision, four (4) hours per month of parent training, and five (5) hours per authorization period of report writing services for a six-month authorization period for all requested services. Based on this definition, the current case does not meet criteria A and C. Specifically, the scope of treatment consisting of 22.5 hours per week of ABA services does not match the objectives identified in the treatment plan. The provider listed four current goals, two revised goals and one held goal. Findings:  the physician reviewer found that the provider describes the patients problem behavior, but there is no data describing the frequency or intensity of these behaviors or a plan to address these behaviors. Follow-up information included a graph of scores on a functional behavior assessment. However, these scores were rendered from a rating scale not discrete data on the behavior itself. Finally, while the social relevance of all behavior is dependent upon the negative impact it has on the patient and those around them, the provider described how the behavior could lead to problems in the future, but failed to describe what problems the behaviors have caused or are currently causing. This suggests that the patients behavioral issues are not a significant concern to address at this time. While the patients intensity is discrepant from the scope of goals identified, they may still benefit from some level of ABA therapy. Since the provider has identified that the patient has some deficits, but the service intensity requested is beyond these deficits, a more focused treatment intensity would be appropriate. Therefore, ABA services, including 12 hours per week of direct behavior technician, five hours per month of direct supervision, and four hours per month of parent training for a six-month authorization period for all requested services are medically necessary for treatment of this patient.Final Result: The reviewer determined that a portion of the requested services are 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 psychology and is a board certified behavior analyst 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 weekly individual therapy services. A study found a mental disorder is defined as a syndrome characterized by clinically significant disturbance in a patients cognition, emotion regulation, for behavior that reflects a dysfunction in the psychological, biological, for developmental process underlying mental functioning. Health literature indicates that functional impairment must be present in order for a set of symptoms to classify as a mental illness. Psychotherapy is effective for symptom management and reduction of relapse risk in patients with bipolar disorder.  The literature does not specify the exact frequency of psychotherapy. Typically, the patients symptom presentation dictates the frequency. This patient meets the criteria for a mental disorder due to emotional dysregulation and difficulty functioning. The records support an indication for therapy. The patient is receiving outpatient therapy on an inconsistent basis for her condition. The providers have recommended group therapy, individual therapy and dialectical behavior therapy (DBT). Given the nature of this patients issues, weekly individual therapy services 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 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 Saxenda. Obesity is a chronic disease. Although diet, physical activity, and behavioral modifications are the cornerstones of weight management, weight loss achieved by lifestyle modifications alone is often limited and difficult to maintain. Pharmacotherapy for obesity can be considered if patients have a body mass index (BMI) of 30 kg/m2 or greater, or BMI of 27 kg/m2 or greater with weight-related comorbidities. Successful pharmacotherapy depends on tailoring treatment to a patients behaviors and comorbidities. In clinical trials, patients regained weight lost following the weight-loss plateau after stopping the medication. Increasing the duration of treatment does not typically lead to greater loss of weight. The effect of the medication transitions from promotion of weight loss to assisting in weight maintenance. Data suggests that current medications approved for long-term use are effective for weight-loss maintenance. This patient has obesity as determined by the BMI of 32.65 kg/m2 at the start of treatment with Saxenda. Treatment with Saxenda 3 mg a day provided good response as documented by weight loss and reduced BMI. The patients daily medication regimen also includes anti-depressant agents. Most of the weight loss agents that are U.S. Food and Drug Administration (FDA) approved for treatment of obesity are contraindicated or are not safe for this patient. Saxenda is safe and effective for use in this clinical setting. Therefore, the requested Saxenda is supported as 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 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 Radicava. Radicava is U.S. Food and Drug Administration (FDA) approved to slow decline and loss of physical function in patients with amyotrophic lateral sclerosis (ALS). A study found that medical trials demonstrated beneficial improvement on functional ability and slowing clinical decline in ALS with Radicava. Study extension results published also reflected positive benefit of Radicava for treatment of ALS. The medical records provided for review support that this patient has a diagnosis of ALS. The available medical records are consistent with a progressive disorder that is progressing in terms of affecting his neurologic ability. However, the patients ALS Functional Rating Scale (ALSFRS) (ALSFRS) score should reflect a score two for walking ability, not a one, as noted in the records. A score of two is appropriate when a patient can walk with assistance. A score of one denotes only non-ambulatory functional movement. This patient is able to ambulate with the use of assistive devices. As such, all of the elements of the ALSFRS at the time medication was to be started were two or greater, which supports an indication for Radicava. Moreover, the timeframe of diagnosis was less than two years ago, as recommended by the guidelines. As such, the medical records demonstrate that the patient meets the recommendations in the medical literature for the treatment with Radicava. Therefore, treatment with Radicava is medical 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a powered pressure-reducing air mattress.  Findings:  The physician reviewer found that appropriate management for persistent low back pain begins with a diagnostic work-up to determine etiology. In the setting of generalized benign musculoskeletal low back pain, the focus of treatment should be patient education, self-care, analgesics, topical modalities such as ice and heat, as well as independent exercise. As poor sleep is common in this clinical setting, the medical literature recommends treatment with established sleep interventions such as cognitive behavioral therapy and pharmacological interventions. With respect to bedding and sleep surface selection, the available literature indicates that medium-to-firm mattresses correlate with better sleep quality than softer mattresses. Notably the types of bedding surfaces and mattresses that have been studied and have correlated with more favorable subjective outcomes in patients with low back pain and sleep difficulties do not require a prescription. This patient has chronic low back pain and difficulties with sleep. However, there are no impairments to support use of a hospital bed or a powered pressure-relieving mattress. A powered pressure-relieving mattress is appropriate for patients who are at significantly elevated risk for pressure injury, such as patients with spinal cord injury, and for whom alternative support surfaces would not suffice. Standard interventions are likely to provide this patient with improvement in his symptoms including exercise, activity, and weight loss. Therefore, the requested powered pressure-reducing air mattress is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the equipment 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 physical medicine and rehabilitation 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 facial feminization surgery.Findings:  The physician reviewer found that the World Professional Association for Transgender Health (WPATH) is clear in stating that facial feminization surgery is a medically necessary treatment for gender dysphoria. The WPATH states that facial feminization surgery for some patients is a more necessary surgery than genital surgery and that the medical procedures attendant to gender affirming/confirming surgeries are not cosmetic or elective or for the mere convenience of the patient. The WPATH states 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 (WPATH 2016). Furthermore, Ainsworth and Spiegel have demonstrated that facial feminization surgery, like vaginoplasty, is associated with improved mental health-related quality of life in transgender women (Ainsworth and Spiegel, 2010).In this case, there is substantial documented evidence of the medical necessity of surgery for this patient, including a mental health assessment that establishes that the patient presently has clinically significant distress and functional impairment from Gender Dysphoria. The patients providers have noted that she reports significant distress, anxiety, and depression when seeing pictures or reflections of her face, and that her goals of surgery are to alleviate dysphoria, and to align her outward appearance with her true gender identification. Under these circumstances, the requested facial feminization surgeries are medically necessary to treat 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 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 authorization and coverage for internal medicine with subspecialty certification in cardiovascular disease. The peer-reviewed medical literature has not demonstrated that genetic testing for management of cardiovascular disorders is more beneficial than routine risk analysis and testing. MTHFR testing lacks support to be used as a reliable guide for management of this patients hypertension. Therefore, the requested MTHFR gene analysis and common variants are likely not more beneficial for evaluation of the patients medical condition than any standard therapy available.Findings:  Three physician reviewers found the requested MTHFR gene analysis common variants is not 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 MTHFR gene analysis common variants is 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 subspecialty certification in cardiovascular disease 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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for referral to a fertility specialist. Findings:  The physician reviewer found that the enrollee has a medical history of hyperlipidemia and obesity and presented to an OB/GYN for a pre-conception consult. A prior pregnancy resulted in miscarriage. She is currently single and interested in conceiving this year with donor sperm. Risks of pregnancy, likelihood of conception at advanced maternal age (AMA) and management of her co-morbidities were discussed. The OB/GYN referred the enrollee to a perinatologist for a pre-conception consult. The OB/GYN also referred the enrollee to a reproductive endocrinologist for bloodwork, evaluation, and discussion of intrauterine insemination (IUI). The enrollee presented for a consult with an OB/GYN specializing in maternal and fetal medicine. Risks of co-morbidities during pregnancy and fetal chromosomal abnormalities were discussed. The specialist concluded there are no absolute contraindications to pregnancy and placed a referral to a reproductive endocrinologist. The reviewer determined that, according to the medical literature, the services of a fertility specialist are warranted. Due to her  advanced age, she will be a high risk pregnancy and more immediate evaluation and treatment by a fertility specialist is medically necessary.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 reproductive 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for bilateral breast augmentation. Findings:  The physician reviewer found that the enrollee has gender dysmorphia and is transitioning from male to female. She reports her mental health providers have recommended breast augmentation, laryngoplasty, thyroid cartilage reduction, and facial feminization surgery.  She was seen in consultation for gender related issues and noted that she knew her true gender was female at an early age and she lived as a female often in her life, but had now been living as a female for the past two years. Guidelines from an authority on transgender health issues indicate medically necessary gender affirming/confirming surgical procedures may include breast augmentation for feminization.  The medical procedures related to a gender affirming/confirming surgeries are not cosmetic or elective or for the mere convenience of the enrollee.  These procedures are reconstructive surgeries.  A variety of therapeutic options can be considered for individuals seeking care for gender dysmorphia. These include changes in gender expression and role, hormone therapy to feminize or masculinize the body, surgery to change primary and/or secondary sex characteristics (e.g., breasts/chest, external and/or internal genitalia, facial features, body contouring) and psychotherapy. Although she has not been treated with hormones, the records support the enrollee has been living as a female for years, and desires to have more feminine traits and surgical intervention, inclusive of breast augmentation. Surgical intervention is supported for enrollees with persistent gender dysmorphia.  The enrollee underwent a psychological evaluation and was found to be psychologically sound to have the surgery.  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 child and adolescent 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.