Persius/hicric huggingface dataset:
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 Surgeries (FFS).The World Professional Association for Transgender Health (WPATH) has stated that facial feminization surgery is medically necessary for some patients and may be a more important treatment for gender dysphoria than genital surgery. The WPATH has stated that non-genital surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals and that these interventions 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 (WPATH 2016). Furthermore, Ainsworth and Spiegel have demonstrated that facial feminization surgery, like genital surgery, is associated with improved mental health-related quality of life (Ainsworth and Spiegel, 2010).In this case, the patient has submitted multiple documents that support her claim that the requested facial feminization surgeries are medically necessary. A letter from the patients therapist states that the requested facial feminization surgeries will serve to improve the patients personal safety and mental health-related quality of life. The patients primary care provider also supports the medical necessity of the requested surgeries to treat the patients gender dysphoria. Under these circumstances, the requested Facial Feminization Surgeries (FFS) are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat 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 Kerydin 5% topical solution. The records provided for review document this patient has onychomycosis and dystrophic toenails.  According to the progress notes, the patient did not report pain or limitation of ambulation due to onychomycosis, nor does the progress note advise of painful ingrown toenails or paronychia. In the absence of pain or painful in-growing infected toenails, treatment with Kerydin for onychomycosis is not supported by the medical literature. This patients records do not document that the patient has achieved 48 weeks of treatment with ciclopirox. For these reasons, the requested Kerydin 5% topical solution 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 a licensed D.P.M., board certified in podiatry 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 home health care and skilled nursing visits for administration of IVIG infusions with Gammaplex 10%. Hovaguimian and Gibbons report that management of small-fiber neuropathy depends on the underlying etiology with concurrent treatment of associated neuropathic pain, and may involve the use of antidepressants, anticonvulsants, opioids, topical therapies, and nonpharmacologic treatments as part of the overall management of neuropathic pain. Finnerup and colleagues note that inadequate response to drug treatments constitutes a substantial unmet need in patients with neuropathic pain. In reviewing the efficacy and safety of IVIG for apparently autoimmune small-fiber polyneuropathy, Liu and colleagues suggest that IVIG is safe and effective for rigorously selected patients with small-fiber polyneuropathy with apparent autoimmune causality.  In this case, the patient has a diagnosis small-fiber polyneuropathy and a history of autoimmune conditions. Her symptoms have persisted despite conventional medical therapy. Given current medical literature, the requested services are standard of care and medically indicated. Therefore, home health care and skilled nursing visits for administration of IVIG infusions with Gammaplex 10% 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Supprelin LA 50 MG subcutaneous implant. Researchers note that puberty suppression by means of gonadotropin-releasing hormone analogs has become accepted in clinical management of adolescents who have gender dysphoria. The authors conclude, A treatment protocol including puberty suppression leads to improved psychological functioning of transgender adolescents. While enabling them to make important age-appropriate developmental transitions, it contributes to a satisfactory objective and subjective well-being in young adulthood. The World Professional Association for Transgender Health (WPATH) states, Adolescents may be eligible for puberty suppressing hormones as soon as pubertal changes have begun. In order for adolescents and their parents to make an informed decision about pubertal delay, it is recommended that adolescents experience the onset of puberty to at least Tanner Stage 2. Some children may arrive at this stage at very young ages (e.g., 9 years of age). Studies evaluating this approach only included children who were at least 12 years of age. Two goals justify intervention with puberty suppressing hormones: (i) their use gives adolescents more time to explore their gender nonconformity and other developmental issues; and (ii) their use may facilitate transition by preventing the development of sex characteristics that are difficult or impossible to reverse if adolescents continue on to pursue sex reassignment. In this case, the patient has a diagnosis of gender dysphoria with a providers statement that the requested implant is medically necessary. Therefore, Supprelin LA 50 MG  subcutaneous implant is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested implant 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 psychiatry with expertise in transgender health 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 radiofrequency ablation (RFA) (CPT code 64625). Schmidt and colleagues found that RFA may offer a potential benefit as a therapeutic modality, although limited data support its use as a primary treatment modality. Yang and colleagues concluded that the current evidence suggests that RFA can provide relief of pain that originates from the posterior sacroiliac joint complex. However, the authors noted that the literature is limited by variability in patient selection criteria, specific nerves targeted for ablation, and the types of RFA technology and technique utilized. This patient presents with complaints of grade 6/10 low back and buttock pain. Clinical examination findings revealed tenderness to palpation over the bilateral sacroiliac joints and two positive sacroiliac joint provocative tests. The patient has undergone two sacroiliac joint injections, most recently on 6/10/20, with 70% relief of pain for three weeks. She has reportedly exhausted conservative treatment including pain medications, anti-inflammatory medications, and physical therapy. Her provider has recommended RFA of the left sacroiliac joint. Current evidence-based peer-reviewed medical literature indicates that there are limited data supporting the safety and efficacy of RFA in this clinical setting. Moreover, there is a lack of large volume peer-reviewed outcome studies with long-term follow-up to support the use of RFA for this patient. For these reasons, the requested RFA (CPT code 64625) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested RFA (CPT code 64625) is 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 requested services are 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan. A study notes that rifaximin treatment appears effective and safe for the treatment of small intestine bacterial overgrowth (SIBO). Another study found that rifaximin effectively normalized the glucose hydrogen breath test (GHBT) and reduced the symptoms of irritable bowel syndrome (IBS) by possibly counteracting SIBO. An additional study notes that rifaximin plus neomycin is superior to neomycin alone in improving multiple constipation-predominant IBS symptoms. In this case, the patient has diagnoses of IBS with constipation and SIBO. While antibiotics such as fluoroquinolones may address bacterial overgrowth, they would not be expected to improve irritable bowel syndrome. Given the current medical literature, the requested medication is medically indicated in this clinical setting. Therefore, Xifaxan 550 mg tablets is medically necessary for the 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Advair Diskus aerosol powder 500-50 MCG/dose, 2 puffs a day. The U.S. Food and Drug Administration (FDA) approves the use of Adair Diskus for the management of chronic obstructive pulmonary disease (COPD). In this case, the patient has a diagnosis of COPD and tried and failed multiple alternative therapies. He has demonstrated a positive clinical response to Advair Diskus. Given current medical literature and in this clinical setting, the requested medication is medically indicated. Therefore, Advair Diskus aerosol powder 500-50 MCG/dose, 2 puffs a day is medically necessary for the 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 sub-specialty certifications in pulmonary disease and critical care 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 L4-L5 decompression and fusion surgery. Researchers reported that for patients with degenerative disc disease and stenosis without spondylolisthesis, in the absence of deformity or instability, the inclusion of a fusion was not recommended. Researchers noted that the incorporation of a lumbar fusion may be considered an option when a herniation was associated with evidence of spinal instability, chronic low-back pain, and/or severe degenerative changes, or if the patient participated in heavy manual labor. In this case, the patient had progressively worsening symptoms of chronic axial low back pain, signs of neurogenic claudication, and increasing functional limitations. She has failed conservative treatment, including activity modification, physical therapy, chiropractic, and epidural steroid injection. However, the records do not clearly document a radicular pain pattern consistent with imaging evidence at the L4-L5 level, evidence of spondylolisthesis, or spinal segmental instability on flexion and extension, and do not include a discussion supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. Given current medical literature, in this clinical setting the request services are not medically indicated. Therefore, L4-L5 decompression and fusion surgery is not medically necessary for the 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for durable medical equipment (DME)  powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), custom. The proposed DME is not expected to practically assist this patient in performing any self-care tasks requiring dexterous upper extremity use such as feeding, grooming, dressing, or bathing. The DME does not have the responsiveness or degrees of freedom to assist in these types of tasks in a practical, meaningful, and efficient manner. In addition, this patient has a weak left shoulder, which makes it difficult for him maneuver the left upper extremity, with the weight of the brace added to it, into positions where he can use the brace effectively for the purposes of self-care. Moreover, the requested DME has not been demonstrated to help patients regain neurological or muscular strength or function, such that the patients ability to use the arm for functional tasks is improved when the orthosis is removed. The DME has not been shown to improve health or outcomes following a stroke, such as reducing the incidence of overuse injury of the unaffected limb. There are also safety concerns related to the use of this device, which is heavy and can cause the shoulder to sublux. This can be mitigated with the use of a chest harness, but the need to wear a harness will further reduce the likelihood of adoption of the device in a community setting. The DME may also cause a patient with hemiparesis to have greater difficulties with gait due displacements in the patients center of gravity with use of the device. Given these findings, the requested DME  powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), custom is not medically necessary for treatment of this patient. 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 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 enrollees parent has requested authorization and coverage for hearing loss panel including whole exome and whole genome testing. Based on the available clinical documentation, the request for whole exome and whole genome testing is not likely to be more beneficial in identifying the underlying etiology of this patients congenital hearing loss as compared to available standard interventions. The International Pediatric Otolaryngology Group (IPOG) reported that in the setting of bilateral sensorineural hearing loss, comprehensive genetic testing is the appropriate next step in work-up after physical examination and audiogram. Genetic testing targeting genes linked to syndromic or non-syndromic forms of hearing loss has the highest diagnostic rate of any test in the evaluation of hearing loss following audiometric testing. A comprehensive hearing loss-specific panel is considered more advantageous than whole exome sequencing due to better coverage of targeted areas and genetic variations as well as simpler bioinformatics analysis. Overall, there is inadequate peer-reviewed clinical data to support the use of whole exome and whole genome testing in this clinical setting. Therefore, the requested hearing loss panel including whole exome and whole genome testing is not 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 hearing loss panel including whole exome and whole genome testing 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 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 otolaryngology 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 patient has requested reimbursement for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS framework, this patient met the criteria for RTC services from 2/14/20 through 3/1/20. For dimension 1, the patient was at significant risk of harm (score 3) since the records note that patient snorted Excedrin one week prior to discharge, supporting ongoing substance abuse issues. In addition, while in the RTC, the patient was involved in a physical altercation with a peer. The patient was later able to resolve the situation with the peer, but his behavior raised concerns about his ability to remain safe in a less supportive, supervised, and structured environment. There is indication or report of incidents of acting without thinking and physically aggressive actions that endanger self and others. For dimension 2, the patient demonstrated serious functional impairment (score 4) due to refusal to attend school and highly oppositional and defiant behavior at home. During this admission, the provider noted that the patient was inefficient with his schoolwork and he continued to endorse numerous symptoms of ADHD, supporting continued impaired functioning. Furthermore, he had multiple somatic complaints and serious medical issues which impaired his overall functioning. Inability to perform adequately even in a specialized school setting due to disruptive behavior or inattentiveness. The patients school attendance was sporadic. For dimension 3, the patient has significant medical comorbidities (score 5) including Marfan syndrome, aortic aneurysm, scoliosis, and sleep apnea. The patients aortic aneurysm requires close medical monitoring and sleep apnea can contribute to poor energy and attention as well as mood problems. In addition, the patient has multiple psychiatric comorbidities including ADHD, generalized anxiety disorder, major depressive disorder, and persistent depressive disorder, as well as cannabis use disorder. Medical conditions were present that may adversely affect, or be adversely affected by, the presenting condition.