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

An enrollee has requested authorization and coverage for Otezla 30 mg tablets. Otezla (apremilast) is an FDA-approved, systemic, oral, non-biologic medication used to treat chronic psoriasis with good safety and efficacy profiles. Papp and colleagues performed a phase 2b, multicenter, randomised, placebo-controlled, dose-ranging study and concluded that apremilast, given orally at 20 or 30 mg twice daily, seems to be efficacious, safe, and tolerable for patients with moderate to severe plaque psoriasis. In addition, joint American Academy of Dermatology-National Psoriasis Foundation guidelines give an A rating to the use of apremilast for psoriasis in adults. Specifically, the guidelines state that apremilast is recommended for the treatment of moderate to severe psoriasis in adults. In this case, the patient has chronic plaque psoriasis that requires systemic treatment. Records reflect that the patient is currently responding to Otezla, and the medication is standard of care in the treatment of chronic plaque psoriasis. Under these circumstances, the requested Otezla 30 mg tablets are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.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: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an enrollee has requested authorization and coverage for right mastectomy, simple, complete, right nipple/areola reconstruction, right muscle, myocutaneous, or fasciocutaneous flap, trunk, left mastectomy, simple, complete, left nipple/areola reconstruction, and left muscle, myocutaneous, or fasciocutaneous flap, trunk. The submitted documentation supports that the requested services are medically necessary. Chest surgery for transmasculine youth is a common intervention for gender dysphoria. There is no justification for limiting coverage for treatment to adults. The World Professional Association for Transgender Health (WPATH) Standard of Care, version 7, clearly mentions that chest surgery in Female to Male (FTM) patients could be carried out earlier than the age of majority. The WPATH Standard of Care suggests that patients have ample time of living in the desired gender role and testosterone treatment. Mastectomy with male chest reconstruction in transgender male youth is now commonly done in minors, and has been demonstrated to be a safe and effective treatment for gender dysphoria in this population. In this case, the patient has a history of gender dysphoria, and he has had ample time living as male and is on testosterone. The patient has documentation from both medical and therapy providers of gender dysphoria regarding his chest, and documentation of clinically significant symptoms. Under these circumstances, the requested right mastectomy, simple, complete, right nipple/areola reconstruction, right muscle, myocutaneous, or fasciocutaneous flap, trunk, left mastectomy, simple, complete, left nipple/areola reconstruction, and left muscle, myocutaneous, or fasciocutaneous flap, trunk is 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for high intensity focused ultrasound (HIFU) surgery. HIFU consists of focused ultrasound waves, emitted from a transducer, that cause tissue damage by mechanical and thermal effects as well as by cavitation. HIFU has been increasingly been used for treatment of localized prostate cancer within the last decade. The available literature primarily consists of prospective case series and retrospective studies showing short- to intermediate-term outcomes for localized prostate cancer. There is a paucity of controlled trials available for analysis, and a lack of long-term survival data. The American Urological Association (AUA) states that providers should inform low-risk prostate cancer patients who are considering focal therapy or HIFU that these interventions are not standard care options because comparative outcome evidence is lacking. This patient presented with an elevated PSA. Biopsy demonstrated prostate cancer. Based on the current medical literature, the patient was a candidate for several therapeutic options demonstrated to be safer and more effective for prostate cancer at long-term follow-up than HIFU. Given these findings, the HIFU surgery was 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 services at issue were 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: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for Xtandi (enzalutamide) 160 mg daily. The medical literature supports that the requested medication is medically necessary. The androgen receptor (AR) is expressed in both normal and malignant breast tissue. While luminal, hormone receptor-positive breast cancers more commonly express AR (91 percent), triple-negative breast cancer (TNBC) expresses AR approximately 30 percent of the time. The potent AR inhibitor enzalutamide (Xtandi) was evaluated among 118 patients with AR-positive metastatic TNBC (55 percent of 404 screened). Two complete responses and five partial responses were observed. Clinical benefit rate (CBR) at 16 weeks was 35 percent (95% confidence interval (CI) 24-46), and was 39 percent (95% CI 27-53) among those whose tumors expressed an AR-driven gene signature. In this case, the patient has limited treatment options, and given pathology results showing 100% of cells androgen positive, the patient is likely to have a good response to enzalutamide with limited toxicities. Under these circumstances, the requested medication Xtandi (enzalutamide) 160 mg daily is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certifications in hematology and medical oncology, 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

The patients parent has requested authorization and coverage for applied behavioral analysis (ABA) services consisting of 20 hours per week of direct one-on-one with a paraprofessional; four hours per week of parent training; three hours per week of supervision; and 0.25 hours per week of social skills group. The Behavior Analyst Certification Board (BACB) has provided evidence-based treatment recommendations for patients with autism. The BACB highlights the critical features of an appropriate treatment plan should include target behaviors that are operationally defined, including baseline levels. The behavioral targets section of the patients treatment plan does not include baseline data and the remainder of the patients goals do not include an objective assessment of the patients current skill levels and deficits. The goals reference the patients current Individualized Education Plan (IEP) or approximations of behavior. This lack of objective data makes it difficult to evaluate the patients progress, as there is no understanding of the patients level of behavior at the onset of treatment. Further, 10 of the 18 goals pull directly from the patients IEP, which highlight an educational rather than medical basis. Additionally, the goals are not linked to specific autism criteria. While the provider noted that the patients goals address autism symptoms such as communication, most goals are general self-help and daily living skills that are not specific to autism spectrum disorder. All told, the requested ABA services consisting of 20 hours per week of direct one-on-one with a paraprofessional; four hours per week of parent training; three hours per week of supervision; and 0.25 hours per week of social skills group are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is a licensed BCBA and board certified in psychology 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 patient has requested authorization and coverage for Osmoprep 1.5 gram tablets. This patient presents with rectal bleeding, which is an indication for colonoscopy. The patient has not undergone a screening colonoscopy and rectal bleeding is concerning for colorectal cancer. As bowel preparation has been reported to be the primary obstacle to the patient undergoing a colonoscopy in the past, addressing the tolerability of bowel preparation is important. Comparisons of Osmoprep with conventional bowel preparation have generally shown that Osmoprep, which requires less intake and is thus better tolerated. As this patient has failed three conventional bowel preparations due to the required volume of liquid intake in the past, the requested Osmoprep is appropriate. For these reasons, the requested Osmoprep 1.5 gram tablets are medically necessary for 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 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

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, 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) medical, addictive 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 LOCUS framework, this patient meets the criteria for RTC services. This gives the patient a composite score which is consistent with medically monitored non-residential services. This level of care provides supervision of activities of daily living, which is a requirement for this patient given his decompensation and failure of higher levels of care. All told, the RTC services provided were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement and authorization and coverage for Skilled Nursing level of care. In this case, the patient sustained a fall from an elevated height while intoxicated, resulting in multiple injuries. He required extensive care in the critical care setting. He was medically and surgically stabilized and transferred to a skilled nursing facility for rehabilitation and further care. He had multiple limitations/restrictions due to his underlying injuries, including the need to use a cervical collar at all times, other spinal restrictions, and most significantly, weight bearing restrictions related to both his lower limbs. The patient did not have any active medical or nursing related issues that required ongoing inpatient level care. During the period of care under review, the patients care could have been provided at a lower level of care, e.g., a custodial facility or in the community with custodial level assistance and home health services. Accordingly, Skilled Nursing level of care provided during the period under review was not, and is not, medically necessary for the patient.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary to treat 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

The patient has requested authorization and coverage for voice therapy, including office visit; laryngoscopy telescopic; speech/hearing therapy; laryngeal function studies; and behavioral and qualitative analysis of voice and resonance are medically necessary for treatment of this patient. For transgender females, voice therapy is an important component of treatment to aid in gender transition. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that, for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. The WPATH further supports the incorporation of voice therapy to address a patients gender dysphoria and noted that the discrepancy between outward gender presentation and the felt sense of gender is not trivial; it can impair confidence in communication, comfort with gender presentation, and function in the everyday world. The WPATH SOC recommends voice and communication therapy to help alleviate gender dysphoria and be a positive and motivating step towards achieving ones goals for gender role expression. This patients records demonstrate a history of gender dysphoria. The patients providers have documented that she is misgendered due to the masculine tone of her voice. Given these findings, the requested voice therapy, including office visit; laryngoscopy telescopic; speech/hearing therapy; laryngeal function studies; and behavioral and qualitative analysis of voice and resonance 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ivabradine (Corlanor). Based on the records provided for review, this patient has a history of postural orthostatic tachycardia syndrome (POTS) and she is being treated with low dose carvedilol without any documented trial or intolerance to higher dose beta-blocker therapy. A recent clinic note did not document any tachycardia or hypotension, at baseline or after standing, despite symptom occurrence. Studies evaluating Corlanor for the treatment of patients with POTS have demonstrated lower heart rate and reduced symptoms in some patients. However, the available studies are small and without comparison control groups. The patient has not reported any tachycardia during symptoms while on low dose carvedilol and there is no documented contraindication to higher dose carvedilol therapy. For these reasons, the requested ivabradine (Corlanor) 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 cardiovascular disease 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

An enrollee has requested authorization and coverage for transoral incisionless fundoplication procedure utilizing the EsophyX device. Currently, there are limited data supporting a clinical role for transoral incisionless fundoplication in the treatment of patients with gastroesophageal reflux disease (GERD) who may respond to increased proton pump inhibitor (PPI) dosing. Researchers found that at six months, 59% of chronic GERD patients remained in clinical remission after active intervention. Researchers also reported that after a five-year follow-up, the transoral incisionless fundoplication provided safe and sustained long-term elimination of troublesome GERD symptoms. However, the authors noted that there were three reoperations by the end of the five-year follow-up and 34% of the remaining patients were back on daily PPI therapy. This patients records suggest that her condition is not refractory to PPI therapy given the dosing reported in the chart. Accordingly, the requested transoral incisionless fundoplication procedure utilizing the EsophyX device 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 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 gastroenterology 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: Upheld Decision of Health Plan

The patient has requested reimbursement for magnetic resonance imaging (MRI) of the neck and total disc arthroplasty. This patient underwent evaluation with a cervical spine MRI less than one month prior to the repeat MRI. However, there is a lack of indication for the repeat MRI. The postoperative diagnosis was cervical spondylosis without myelopathy. Currently there are insufficient data demonstrating the long-term safety and efficacy of total disc replacement for the treatment of cervical spondylosis. Specifically, studies have not shown that disc replacement reliably and reproducibly fulfills the three primary aims of continued motion, clinical efficacy, and few adjacent segment degenerative problems. Total disc replacement has been associated with a high rate of future operations, and the potential problems that may occur with longer follow-up have yet to be determined. All told, the MRI of the neck and total disc arthroplasty were medically not necessary for this patient.Final Result: The reviewer determined that the services at issue were 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 neurological 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.