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

The patient has requested authorization and coverage for liposuction of the trunk (abdomen and flanks); tissue transfer trunk 10 square cm or less; tissue transfer trunk 10.1 to 30.0 square cm; tissue transfer any area 30.1 to 60.0 square cm; and tissue transfer any area each additional 30 square cm. The World Professional Association for Transgender Health (WPATH) lists surgical procedures for the treatment of gender dysphoria for female-to-male patients as including, Nongenital, nonbreast surgical interventions: voice surgery (rare), liposuction, lipofilling, pectoral implants, and various aesthetic procedures. WPATH notes, Non-genital surgical procedures are routinely performedthese surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals. In this case, the patient is diagnosed with persistent gender dysphoria, and his providers state that the requested services are medically necessary. Therefore, liposuction of the trunk (abdomen and flanks); tissue transfer trunk 10 square cm or less; tissue transfer trunk 10.1 to 30.0 square cm; tissue transfer any area 30.1 to 60.0 square cm; and tissue transfer any area each additional 30 square cm 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement for residential treatment center (RTC) services. Per American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Given the findings, the patient met the six ASAM criteria for RTC services. Accordingly, the RTC services provided were medically necessary for 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 subspecialty certification in addiction 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: An enrollee has requested authorization and coverage for pioglitazone HCL 30 mg tablets.The American Diabetes Association (ADA) recommends a target HbA1c of less than 7% in order to decrease the risk of micro and macrovascular complications. The ADA also recommends diet management and weight lost for better glycemic control. In this case, the patient's type 2 diabetes was in poor control with a reported HbA1c level of 11-13% on a regimen of glipizide and metformin. The patient was also noted to have had difficulty in achieving weight loss. The patient was started on pioglitazone after the combination of glipizide and metformin was ineffective. This is a triple therapy regimen that is recommended by the ADA, and the patient is following ADA guidelines by using glipizide, metformin and pioglitazone. Accordingly, pioglitazone HCL 30 mg tablets are medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's condition. Therefore, the Health Plans denial should be overturned.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Dupixent. The enrollee has a history of severe, refractory atopic dermatitis and persistent, uncontrolled asthma. She had been treated with steroid creams and immunotherapy. A progress note reported the enrollees skin is clear of rashes, except for eczema to the face, waist and groin area. The note reported the enrollees scalp and nails were normal. Medical records do not demonstrate the enrollee has atopic dermatitis on at least 10 percent of the body or more. The medical records do not show the enrollee had attempted treatment with topical tacrolimus or topical pimecrolimus and then one of the following: phototherapy, methotrexate, azathioprine, intermittent/pulse therapy with oral steroids, mycophenolate mofetil, or cyclosporine. The physical examination of the lungs and skin were reported as normal. There is no mention of prior use of Dupixent in the notes provided. The progress notes do not mention the prior use of systemic immunomodulatory drugs or calcineurin inhibitors for atopic dermatitis. A pharmacy services note shows that a mild steroid cream and Eucrisa had been used in the past. There is inadequate evidence to support moderate to severe atopic dermatitis, based on the medication trials and physical examination findings documented in the progress notes provided.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in allergy and immunology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for shoulder surgery. Researchers concluded that there is limited evidence that surgery is more effective in treating rotator cuff tear than conservative treatment alone. Thus, the providers recommend a conservative approach for initial treatment. This patient presents with chronic grade 10/10 left shoulder pain, significant loss of range of motion, and weakness. The patient reports functional limitations with activities of daily living. Clinical examination findings are consistent with imaging evidence of rotator cuff tendinopathy and adhesive capsulitis. Conservative treatment has included activity modification, medications, and home exercise. A corticosteroid injection was performed with no documentation of response or follow-up. The provider reports that given the patients lack of ability to engage in physical therapy, surgery might be more complicated and have a worse outcome. Overall, there is an absence of a specific treatment plan and documentation of post-injection follow-up to support an indication for surgical intervention. Based on the available records, the requested shoulder surgery is 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 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

The patient has requested authorization and coverage for proton beam radiation therapy. Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. A position statement released by The American Society of Radiation Oncology (ASTRO) stated that, the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. This patient presents with Gleason score 3+3 prostate cancer, with an elevated PSA. In this clinical setting, the peer-reviewed medical literature supports treatment with photons and IMRT. Therefore, the requested proton beam radiation therapy is 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 board certified in radiation 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 patient has requested authorization and coverage for radiofrequency ablation of the right and left perforator veins with possible ultrasound guided sclerosant. Currently, this patient does not have ulceration and there is untreated significant reflux in the bilateral GSV. Due to the elevated risks of deep vein thrombosis (DVT) and procedural failure, treatment of perforator vein reflux is reserved for patients with recalcitrant ulcers. This patients symptoms are likely to improve with further GSV treatment. Based on the available documentation, the requested radiofrequency ablation of the right and left perforator veins with possible ultrasound guided sclerosant is 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 board certified in surgery with subspecialty certification in vascular 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for Hydrogel Spacer (SpaceOAR) to be used during an upcoming prostate procedure. This patient presents with Gleason 3+3 in two cores on the right and Gleason 3+4 in one core on the left and an elevated PSA. His provider has recommended radiation therapy with use of SpaceOAR spacers. Clinical studies have demonstrated that the dosimetric benefit of perirectal spacers decreases radiation side effects and improved quality of life (QOL). Researchers reported that the available data supports a decrease in rectal and bladder toxicity, and shows that perirectal spacers allow for decreased dose to the penile bulb. Based on current peer-reviewed medical literature, the requested Hydrogel Spacer (SpaceOAR) to be used during an upcoming prostate procedure is 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 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: Physician reviewers 1, 2, and 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: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement and authorization and coverage for residential treatment center (RTC) services. The American Society of Addiction Medicine (ASAM) criteria is a validated placement tool. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. In this case, using the ASAM 3.5 criteria, the patient meets all six dimensions for level 3.5 residential treatment center (RTC) level of services. Accordingly, residential treatment center (RTC) services were, and are, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for facial feminization surgery services genioplasty, rhinoplasty, and septoplasty. Researchers reported, Transwomen have diminished mental health-related quality of life compared with the general female population. However, surgical treatments (e.g. facial feminization surgery, gender reassignment surgery, or both) are associated with improved mental health-related quality of life. The World Professional Association for Transgender Health (WPATH) position statement notes, Non-genital surgical procedures are routinely performed notably, subcutaneous mastectomy in female-to-male transsexuals, and facial feminization surgery, and/or breast augmentation in male-to-female transsexuals. These surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals. The WPATH position statement also states, The medical procedures attendant to gender affirming/confirming surgeries 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. The medical evidence supports the requested services in this clinical setting. Therefore, facial feminization surgery services genioplasty, rhinoplasty, and septoplasty 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for thoracic spine magnetic resonance imaging (MRI) without contrast. The decision to obtain specialized cross-sectional imaging of the spine involves multiple considerations. While pain is a common and significant complaint, not everyone who has pain needs a computed tomography (CT) scan or magnetic resonance imaging (MRI). As a fundamental principle, an imaging study is only necessary if it will affect the management of the patient. In this case, given the patients negative thoracic spine x-ray, the likelihood of detecting a significant abnormality following MRI that would change the management of the patient is minimal. As has been shown in multiple studies, incidental finding of degenerative disease or disc abnormality are exceedingly common in asymptomatic individuals. Some patients with substantial MRI findings will not have symptoms, and conversely, some patients with minimal signs on MRI will have pronounced symptoms. In this case, the patient has no symptoms other than pain, which she reports having had for at least five years. There is no evidence of radiculopathy, prior tumor, or infection. While it is always possible that random testing of any organ will demonstrate a significant finding, the likelihood is slim. It has been noted that a diagnosis of type III Ehlers-Danlos Syndrome (EDS) has been considered for the patient. EDS is, for the most part, a clinical diagnosis. While there are genetic tests available to make a diagnosis of EDS, these are not readily available. There are no clearly diagnostic imaging tests to confirm this diagnosis, and a thoracic spine MRI would not be helpful. Under these circumstances, the requested thoracic spine magnetic resonance imaging (MRI) without contrast is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services 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 diagnostic radiology 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

This patient has Erdheim-Chester disease (ECD) and bone metastasis from prostate cancer. He is being treated with Mekinist with a good response, per the medical records. At issue is whether the requested whole body Positron Emission Tomography (PET) Scan with Computed Tomography (CT), is medically necessary to treat the enrollees medical condition. The patients ECD disease process and response to treatments has been monitored with PET-CT scans. Treatment is largely experimental since there are no clear recommendations or outcomes to guide therapy. Thus, monitoring response to therapy is largely on a case-by-case basis. The literature reports that PET-CT scans are used to determine response and adjust treatment based on imaging results and are performed every 2-6 months after initiation of a new therapy for response assessment. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for hypoglossal nerve stimulator surgery. Obstructive sleep apnea (OSA) is an increasingly prevalent clinical problem with significant effects. Continuous positive airway pressure (CPAP) has demonstrated excellent efficacy and safety for treatment of OSA. In patients who do not tolerate CPAP, or fail to improve with an oral appliance, surgical intervention may be required. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. As reported in the published medical literature, the STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of. The authors reported the hypoglossal nerve stimulator is safe and effective in patients with OSA who have nonconcentric airway collapse, an apnea/hypopnea index (AHI) between 20 and 50, and a body mass index (BMI) less than 32. This patient meets the criteria for the requested procedure and no evidence of complete concentric collapse at the nasopharynx, velopharynx, or soft palate on sleep endoscopy. In addition, he has failed CPAP, which is the gold standard treatment for OSA. Moreover, the provider noted that treatment with an oral appliance is not likely to be effective due to the severity of the patients OSA. For these reasons, the requested hypoglossal nerve stimulator is 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 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: Physician reviewer 1 is board certified in otolaryngology and is actively practicing. Physician reviewer 2 is board certified in otolaryngology with subspecialty certification in sleep medicine and is actively practicing. Physician reviewer 3 is board certified in otolaryngology and is 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.