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 bilateral breast liposuction surgery for treatment of the enrollees gynecomastia. Findings:  The physician reviewer found that there is support in the medical literature for the requested services in this clinical setting. In this case, the patients breast enlargement is due to the patients hepatic failure.  Liver disease is a well-documented cause of breast enlargement. The patient has large breasts due to hormonal imbalance and this will unlikely resolve without surgical intervention. The procedure will restore this patients chest to a more male appearance. The large breasts in this patient is an abnormal structure of the body for a male. The bilateral breast liposuction will provide a more than minimal improvement in the appearance of this patient. Therefore, bilateral breast liposuction surgery is medically necessary for treatment of the patients medical condition and is reconstructive in nature.  Final Result: The reviewer determined that the requested services are medically necessary and are reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for finasteride 1 mg. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Finasteride 1 mg is approved by U.S. Food and Drug Administration for treatment of male pattern baldness. The current medical literature does not support the efficacy of finasteride 1 mg in the management of patients with benign prostatic hyperplasia. In addition, the submitted medical documentation does not support the diagnosis of benign prostatic hyperplasia, as symptoms related to benign prostatic hyperplasia are not documented. All told, finasteride 1 mg is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in urology 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: The patient has requested reimbursement for the proton beam radiation therapy provided Findings:  The physician reviewer found that there is currently a lack of medical literature to support treatment with proton beam radiation as compared to conventional radiation therapy for patients with metastatic renal cell cancer to the lung. Standard treatment with photon radiation is associated with a very low risk of toxicity. In addition, there is a paucity of data demonstrating that treatment with proton techniques improves sparing of the surrounding normal structures compared to standard photon techniques using intensity modulated radiation therapy (IMRT) or stereotactic body radiotherapy (SBRT). Further, consensus group guidelines do not support the use of proton therapy in this setting. Based on these reasons, the proton beam radiation therapy provided was not likely to be more beneficial than standard therapy.Final Result: All three of 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 & 3 are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric emergency medical services. Findings:  The physician reviewer found that the medical services provided were necessary for treatment of a psychiatric emergency medical condition. Bipolar disorder is chronic and often disabling serious mental illness. Bipolar disorder is associated with poor clinical outcomes and a heightened rate of suicide. As such, potentially emergent physical symptoms in context of bipolarity should be addressed quickly and comprehensively. In this case, the patient presented with a non-specific but potentially concerning symptom complex. Further medical and psychiatric assessment to rule out life-threatening conditions such as suicidality, psychosis, stroke, myocardial infarction, infection and arrhythmia were emergent in nature. Thus, the services at issue were necessary for treatment of a psychiatric emergency medical condition. Final Result: The reviewer determined that the patient received psychiatric emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: An enrollee has requested authorization and coverage for hormone growth replacement therapy for treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that the request for hormone growth replacement therapy is medically necessary for treatment of the patients medical condition. Nutropin is a recombinant GH which is used as replacement therapy in adult GH deficiency. In this case, the patient had a motor vehicle accident followed by symptoms of frequent headaches, insomnia, short-term memory loss, emotional lability, irritability, light sensitivity, vertigo, fatigue and poor organization skills. Although the patients IGF-1 level was within the normal reference range, the patients glucagon stimulation testing confirmed GH deficiency per Endocrine Society guidelines. 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 endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha Sureclick 140 mg/mL for treatment of the enrollees hyperlipidemia and coronary artery disease. Findings:  The physician reviewer found that the request for Repatha Sureclick 140 mg/mL has been established as medically necessary for treatment of the patients medical condition. Based on the records provided the patient has not been able to tolerate moderate or high dose statin or Zetia. Repatha is U.S. Food and Drug Administration (FDA) approved for individuals with genetic hyperlipidemias or for established atherosclerotic vascular disease and failure to achieve treatment goals for lipid lowering at maximally tolerated doses of statins. In this case, the patient meets these criteria. 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for Nuplazid. Findings:  The physician reviewer found that Pimavanserin (Nuplazid) is the first U.S. Food and Drug Administration (FDA) approved atypical antipsychotic drug indicated for the treatment of hallucinations and delusions associated with Parkinsons disease psychosis. Pimavanserin exhibits a unique pharmacological profile with nanomolar affinity at serotonin 5-HT2A and 5-HT2C receptors. Functionally, it acts as a potent inverse agonist at 5-HT2A receptors, with selectivity over 5-HT2C receptors and no appreciable activity at other neurotransmitter receptors. Behavioral studies found that pimavanserin reversed impaired behaviors in animal models predictive of antipsychotic activity, and with no impairment of motor functions. The mechanism of action pimavanserin might contribute to its unique psychopharmacological properties in the improved treatment of Parkinsons disease psychosis. In this case, the patient has been treated with and failed treatment with Seroquel in 2013 and had a positive response to Nuplazid. Given these findings, the requested Nuplazid is supported as medically necessary for treatment of this patients Parkinsons disease and psychosis. 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 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 parent of an enrollee has requested reimbursement for intensive outpatient program (IOP) services. Findings:  The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) criteria is used to objectively determine if the patient meets criteria for length of stay. This is an accepted, national standard for determining the appropriate level of care for children and adolescents. According to CALOCUS criteria, the patients risk of harm is scored a 2, which correlates to some risk of harm.  The patient was successfully detoxed from substances and did not present with acute withdrawal symptoms. The patients functional status is scored a 3, moderate functional impairment. The patient was expelled from two to three schools. The patient was failing his classes.  The patient had conflicted relationships with his parents. The patients recent gains have been achieved in a structured setting. The patients comorbidity is scored a 3, significant comorbidity. The patient has a comorbidity of sedative, hypnotic, anxiolytic use disorder, major depressive disorder, and generalized anxiety disorder. The patient did not have any medical problems, which required 24 hour monitoring. The patients recovery environment is scored a 3 which correlates to moderately stressful environment. The record notes that he has had conflicts with family members over his substance use, which has caused a moderately stressful environment. His environmental support is scored a 2, supportive environment.  The patient has supportive parents who are willing to participate in treatment if asked to do so. The patients resiliency is scored a 3, equivocal response to treatment. The patient has improved in his RTC and IOP treatments. However, recovery has been maintained for moderate periods of time in structured settings. The patients acceptance and engagement is scored a 2, constructive. The patient is cooperative with staff. The patient seems to be passively participating in treatment. According to CALOCUS, the patients composite score is 18. Therefore, based on these criteria, the patient did meet criteria for IOP during the dates of service in dispute. As such, intensive outpatient program services were medically necessary for the 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 with expertise in 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 a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for psychiatric emergency medical services. Findings:  The physician reviewer found that based on the documentation submitted for review, the patient did not receive emergency medical services during the dates of service at issue. In this case, the IOP services were not emergency medical services as the medical records do not show that an emergency existed. The patient presented with depression and anxiety. There was no evidence that the patient was at risk of self-harm or presented with active medical problems or severe psychiatric symptoms. In sum, the services at issue were not emergent in nature. For the reasons provided, the patient did not receive psychiatric emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in 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 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 Exalgo extended release 12 mg. Findings:  The physician reviewer found that based on current medical literature and in consideration of the presented clinical records, Exalgo is not medically necessary for treatment of this patients medical condition. The medical records have shown the patient to have chronic nonmalignant pain. The current standard of care for chronic pain is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections. Based on a study there are Well-established guidelines for routine back pain stress conservative management, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy, but avoiding early imaging or other aggressive treatments, except in rare cases, such as acute neurologic compromise or other red flags, including a history of malignant neoplasms. Similar findings are reflected in a report which states that Conservative decisions in the treatment of degenerative disc disease are based on interventions made for patients with chronic low back pain (LBP). Furthermore, these therapies work best in a multidisciplinary rehabilitation context. Pain medication is needed for most patients with degenerative disc disease, and surgery may be needed for a minority only. There are a variety of anticonvulsants and antidepressants that are considered adjunctive to pain management therapy. If there is poor response to conservative therapy, then surgery should be considered. The medical evidence shows that high dose opioids are associated with a high risk of dependence and tolerance. Therefore, they are not recommended in this clinical setting. Accordingly, Exalgo ER 12 mg is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for tongue tie surgery. Findings:  The physician reviewer found that there is sufficient support in the documentation provided for the requested procedure in this clinical setting. Ankyloglossia is a congenital condition in which an infant has an abnormally short of thick lingual frenulum, limiting the movement of the tongue anteriorly or posteriorly. It is typically noticed upon inability to breastfeed successfully. It is more common in males and occurs in 5 to 10% of live born infants. While typically associated with limitations in breastfeeding in young infants, ankyloglossia also can have other negative sequelae, such as choking and difficulty advancing the diet such as in this patients case. Delay in speech and language development may also occur due to this condition. Intervention includes frenotomy for young infants and frenectomy with or without frenoplasty in the older infant and child. According to the medical literature, these are safe procedures with associated benefits in breastfeeding, eating, and talking. This patient was noted to have ankyloglossia when he developed choking upon introduction of solid foods. Although solid foods are age and nutrition appropriate for him, there is concern for choking hazard and aspiration in his current state. In addition, speech and language development may be negatively affected by restricted tongue movement. Surgical intervention is recommended and clinically appropriate. Therefore, tongue tie surgery is medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested procedure 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 pediatrics 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 reimbursement for vaginoplasty and prospective authorization and coverage for follow-up surgery for treatment of the enrollees gender dysphoria.  Findings:  The physician reviewer found that based on the documentation provided, the patient has gender dysphoria and is in the transition. Based on the patients gender dysphoria and identification as a female, a normal appearance of the genitals is the goal. The patients genital anatomy should be consistent with her gender. The patients gender dysphoria is well documented. The medical literature support bilateral orchiectomies and vaginoplasty as part of the surgical transition process for male to female transition. The patient has abnormal genitalia for a female that would not resolve with continued hormonal therapy. The patients age of 16 should not be used as a sole determinant of medical necessity. The records provided include documentation from providers from various disciplines who report the patients history of gender dysphoria. Therefore, vaginoplasty and prospective authorization and coverage for follow-up surgery scheduled were and are medically necessary for the treatment of this patients gender dysphoria. With regard to whether the services at issue were and are reconstructive in nature, the submitted documentation reveals that the patients male genitalia constitutes an abnormal structure of a female body. Based on the patients gender dysphoria and identification as a female, a normal female appearance of the patients genitalia is the ultimate goal. The genitalia of this patient should be more consistent with a female. The male genitalia can be considered a developmental abnormality of a female. The services at issue would offer more than a minimal improvement in the appearance of this patients genitalia. Final Result: The reviewer determined that the services at issue were and are medically necessary and were and are reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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.