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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Saxenda. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients obesity. The submitted documentation does not support the medical necessity of the requested medication. Saxenda is approved for the treatment of obesity. It is used in adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index greater than 30 kg/m2 or greater than 27 kg/m2 in the presence of at least one weight-related comorbid condition, including hypertension, type II diabetes mellitus, and/or dyslipidemia. Initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention consisting of a combination of diet, exercise, and behavioral modification. Per the medical evidence, patients who would benefit from weight loss should receive counseling on diet, exercise, and goals for weight loss. When a patient with an initial body mass index greater than 30 kg/m2 or a body mass index of 27 kg/m2 with comorbidities, such as hypertension or diabetes mellitus, has failed to achieve weight loss goals through diet and exercise alone, a pharmacologic therapy is suggested. In this case, the documentation does not support that the patient has failed treatment with counseling, calorie restriction, and increased physical activity to achieve weight loss goals. Additionally, the requested non-formulary drug, Saxenda, would not be more effective than the Health Plans formulary drugs, phentermine, benzphetamine, diethylpropion, and phendimetrazine.  There is a lack of studies that demonstrate that Saxenda is more effective than the listed formulary drugs. Therefore, Saxenda 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 internal 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: A transgender female enrollee has requested reimbursement for facial feminization surgeries (frontal orbital bone contour; brow lift with endotine; rhinoplasty; jaw/chin contour). Gender dysphoria refers to distress that is caused by a discrepancy between a persons gender identity and that persons sex assigned at birth. This often results in depression and anxiety. Treatment for gender dysphoria (including surgery on some occasions) aims to minimize dysphoria and help patients attain their sought-after gender role. Researchers find that facial feminization procedures are not cosmetic, but rather serve a primarily reconstructive purpose in transgender women whose overall physical appearance otherwise prevents them from being perceived as female. Researchers note that the medical procedures attendant to sex reassignment 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. Researchers find that gender reassignment is the only treatment for gender dysphoria that has shown significant benefits in numerous research trials and meta-analyses over the past half century. In sum, based upon the submitted clinical documentation establishing the severity of the patients gender dysphoria related to her facial features, as well as the available literature demonstrating the medical necessity of gender reassignment procedures including facial feminization for the treatment of gender dysphoria, the services at issue were medically necessary and appropriate for treatment of this patients condition.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 treatment of gender dyphoria 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: A enrollee has requested authorization and coverage for Norco and promethazine. Findings:  The physician reviewer found that opiates are not considered a first-line therapy for the treatment of headaches. Moreover, there is ample data to suggest that medication overuse headache promotes the chronicity of the headache, as is likely the situation in this patients case. While some providers use limited amounts of opiates as rescue from severe migraine, there has to be close supervision and limits on use. Moreover, promethazine may lead to tardive dyskinesia. As there are non-opioid therapies available for treatment of this patients headache and the chronic use of opioids is likely contributing to her symptoms with medication overuse headache, the requested Norco and promethazine are not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medications 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for surgery to remove pancreatic cysts. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients medical condition. The submitted documentation does not support the medical necessity of the requested services. Surgical consultation has been performed. The provider recommended against surgery due to the benign nature of the enrollees medical condition. Biopsy was confirmatory for an inflammatory (non-malignant) condition. Pancreatic cyst excision would require enteric reconstruction and resection. The risks of this operation include anastomotic leak, peritoneal sepsis and bacteremia. This patients reports of pain are subjective and felt not to be related to the patients medical condition. Risks of surgery are too high to warrant resection for a benign condition. As such, non-operative management with pain management referral is most appropriate. Therefore, the requested surgery to remove pancreatic cysts is not medically necessary for the treatment of the 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 surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: According to recent American Diabetes Association (ADA) guidelines, most patients using intensive insulin regimens (multiple-dose insulin or insulin pump therapy) should perform [self-monitoring blood glucose] SMBG prior to meals and snacks, at bedtime, occasionally postprandially, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycemic, and prior to critical tasks such as driving. For many patients, this will require testing 6-10 (or more) times daily, although individual needs may vary. The notes provided for review indicate that this patient is on an insulin pump that requires use of the Freestyle Lite test strips. This is true for the Omnipod insulin pump system. Freestyle meters require the smallest blood sample size. So for a young patient that is self-monitoring 10 times a day, this is very important. In the latest review of glucose meters, the Freestyle sample size is 0.3 microliters versus AccuCheck which is 0.6 microliters. Given these findings, the requested Freestyle Lite test strips (300 strips per month) are medically necessary for evaluation of this patients type 1 diabetes. Final Result: The reviewer determined that the requested supplies are medically necessary for evaluation 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography (CT) guided cryoablation of lung metastases. Findings:  Two of the three physician reviewers found there is a lack of support for the requested services in this clinical setting. The gold standard palliative treatment of symptomatic pulmonary metastasis is external beam radiation. In asymptomatic patients with pulmonary metastasis, the approach includes systemic therapy. Other systemic treatments which may be beneficial have not been tried. Therefore, CT guided cryoablation of lung metastases is not likely to be more efficacious than other treatment options. 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 internal medicine with sub-specialty certification in medical 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for residential treatment services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.Findings: The documentation provided does not support the services at issue in this clinical setting. On 6/8/18, the patient requested an emergent appointment with her therapist and psychiatrist. The type of emergency was not noted in the documentation. Per the record, the patient was given an appointment with her psychiatrist on 6/28/18 and an appointment with her therapist on 7/11/18. The patient felt that this was too long for treatment. The patient did not endorse suicidal or homicidal ideation. The provider discussed treatment options available with patient. A two to three week wait to see a psychiatrist for an outpatient visit with access to emergency services is considered standard of care. There is no documentation of the patients current weight, body mass index, or ideal body weight. The patient reported that outpatient care has not helped her condition. Her medical note on 5/16/18 stated that her Behavioral Impairment Index (BHI) has decreased from 98 on 7/26/17 to 68 on 5/16/18. The patients health questionnaire (PHQ-9) score has decreased from 23 on 7/26/17 to 16 on 5/16/18. Based on the records provided, the patient has been making progress in her recovery while participating in outpatient treatment. The patients mother is supportive of the patient. The standard of care for residential treatment for eating disorders is reserved for patients who have an ideal body weight less than 80%. In this patients case there was no documentation stating that the patient had an ideal body weight less than 80%. The patient did not endorse suicidal or homicidal ideation. While the patient continues to require treatment for her borderline personality disorder and eating disorder, treatment can be accomplished in a less restrictive environment. Therefore, residential treatment services are not medically necessary for treatment of this patients medical condition.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 psychiatry with expertise in eating disorders 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implant of hypoglossal nerve stimulator (Inspire Upper Airway Stimulation System (CPT codes 64568, 0466T and 95970)). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea.Findings: There is support in the medical literature for the efficacy of the requested services in this patients case. The U.S. Food and Drug Administration has approved this device for the treatment of OSA. The records demonstrate that this patient has severe OSA and has not been able to tolerate the CPAP device. In addition, the patient had a drug induced sleep endoscopy, which showed anterior posterior collapse and no concentric collapse. Accordingly, with an AHI of 46 and a body mass index less than 32, the patient meets criteria and is a good candidate for the device. As such, implant of hypoglossal nerve stimulator (Inspire Upper Airway Stimulation System (CPT codes 64568, 0466T and 95970)) for treatment of this patients OSA is likely to be more effective than any available standard treatment modality.Final Result: All three reviewers determined the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  All three reviewers are board certified in otolaryngology and are actively practicing. All three 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: An enrollee has requested authorization and coverage for nintedanib (OFEV). The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees idiopathic pulmonary fibrosis.Findings:  Ofev (nintedanib) is U.S. Food and Drug Administration approved and its use in this clinical setting is supported by the medical literature to delay disease progression. Published medical literature indicates, Nintedanib, a receptor blocker for multiple tyrosine kinases that mediate elaboration of fibrogenic growth factors (e.g., platelet-derived growth factor, vascular endothelial growth factor, fibroblast growth factor), appears to slow the rate of disease progression in IPF In clinical trials, the main benefit of nintedanib is a reduction in the rate of decline in lung function. In this patients case, he meets criteria for treatment with Ofev (nintedanib) with documented decline in his functional status. The requested medication delays the rate of disease progression in patients who are diagnosed with IPF. This patient has had a decline in his lung function and could benefit from treatment with the requested medication. Accordingly, Ofev (nintedanib) has been demonstrated as medically necessary for the treatment of this patients medical condition.Final Result: The reviewer has 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 pulmonary 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for DaT SPECT scan of the brain. The Health Plan has denied this request indicating that the requested services are investigational for evaluation of the enrollee who presented with parkinsonian features.Findings The medical evidence indicates that Parkinsons disease is the second most common neurodegenerative disease.  Its diagnosis is determined by clinical means, which can lead to error. There are studies that have indicated that patients with presumed Parkinsons disease did not have Parkinsons. Several Parkinsons like diseases including multiple system atrophy, progressive supranuclear palsy, corticobasilar degeneration, and essential tremor can have Parkinsonian features and make them difficult to distinguish. Dopamine transporter scan (DaT) uses SPECT imaging to determine presence, location, and amount of dopamine transporters in dopaminergic cells. It is effective in distinguishing those individuals with parkinsonian syndromes from those with Parkinsons diseases, which can improve and change management of a patient. Accordingly, the requested DaT SPECT scan of the brain is likely to be more beneficial for the evaluation of this patients medical condition than any available standard therapy.Final Result: All three reviewers determined the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  All three reviewers are board certified in neurology and are actively practicing. All three 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a speech therapy evaluation. This patient is demonstrating some challenges with learning that could be related to ADHD or dyslexia. However, speech therapy is not the appropriate approach to identify the patients current difficulties. Previous testing suggested significant problems with articulation and intelligibility. Therefore, the patient requires further cognitive and achievement testing which can be performed through the school or with a psychologist. Based on the previous testing, she does not need a speech and language evaluation. Thus, the requested speech therapy evaluation is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with expertise in neurodevelopmental behavioral 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a speech therapy evaluation for possible dyslexia. This patient is demonstrating some challenges with learning that could be related to ADHD or could be related to dyslexia. However, speech therapy is not the appropriate approach to identify whether she has dyslexia. Previous testing suggested significant problems with articulation and intelligibility. Therefore, the patient requires further cognitive and achievement testing which could be performed by the school or with a psychologist. Based on the previous testing, she does not need a speech and language evaluation to identify dyslexia. Thus, the requested speech therapy evaluation is not medically necessary for further evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with expertise in neurodevelopmental behavioral 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.