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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral breast mastectomy with nipple/areola reconstruction for treatment of the enrollees gender dysphoria and are not reconstructive in nature. Findings:  The physician reviewer found that There is support in the medical literature for the services at issue in this clinical setting. This patient has documented gender dysphoria and is in transition to becoming a male. In determining medical necessity, the patients age should not be the sole determining factor. In this patients case, the records note evidence of abnormal breasts for a male despite the use of hormonal therapy and this medical condition would not likely resolve with continued hormonal therapy. The photographs support the patient has significantly female appearing breasts. Since this patients condition has not resolved despite an adequate course of hormone therapy, surgical intervention to treat this patients gender dysphoria is medically indicated. Therefore, bilateral breast mastectomy with nipple/areola reconstruction are medically necessary for treatment of this patients gender dysphoria.With regard to whether the requested services are reconstructive in nature, the submitted documentation as well as the photographs reveal that the patients breast development constitutes an abnormal structure for a male who has failed hormonal therapy. The patients breast development constitutes an abnormal structure of the body. The appearance of the patients breasts should be more consistent with adult male breasts. The abnormal structure of the body is caused by a developmental abnormality, specifically, the patients gender dysphoria. The plan of the surgery is to create a more normal appearance for a male and to create a relatively normal appearing male chest.  Additionally, the surgery would offer more than a minimal improvement in the appearance to the best extent possible. In summary, bilateral breast mastectomy with nipple/areola reconstruction are reconstructive in nature. 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 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the emergency services provided. The records indicate that the patient had a long history of mental illness. The records indicate he had received treatment for ADHD in the past. He presented to the treatment center with signs of depression and anxiety as well as a desire to receive substance use treatment. The provider has indicated that other programs are not geographically close to the patient. This review was conducted to determine whether the patient received emergency medical services. The records indicate the patient received the full biopsychosocial assessment at the time of admission. There is no indication the records that any of the services provided were emergent nature. Rather, the records suggest the services were a planned form of treatment for the patients mental health and substance abuse issues. The patient did not have any symptoms such as suicidal or homicidal ideation and there was no evidence of acute episodes of psychosis or any other emergency psychiatric symptoms that would require emergent treatment and necessitate emergency stabilization. Residential treatment is used for acute stabilization and is not evidence based for long-term type treatment. Outpatient treatment and least restrictive options are considered first-lines of care as referenced by the American Academy of Child and Adolescent Psychiatry (AACAP) which recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. All told, the services at issue were not necessary for treatment of an emergency medical condition. Thus, 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for facial laser hair removal or treatment of the enrollees gender dysphoria.  Findings:  The physician reviewer found that The requested services are medically necessary in this clinical setting. Facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. The record notes that hormone therapy has not been effective in treating this patients excessive facial hair. The patient has reported anxiety over being misgendered despite hormone therapy. Therefore, facial laser hair removal is medically necessary for treatment of this patients gender dysphoria.With regards to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is considered an abnormal body structure. It would be abnormal for a female to have terminal hair on the face. This type of hair growth in a female is known as hirsutism. The patients abnormal appearance is the result of gender dysphoria, a disease classified in the Diagnostic and Statistical Manual of Mental Disorders.  The requested facial laser hair removal can provide substantial improvement in the appearance of terminal hair and create a normal appearance to the extent possible. Laser hair removal would also provide more than a minimal improvement in the appearance of this patient as well as improve the patients emotional function. For these reasons, facial laser hair removal is reconstructive in nature.  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 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for growth hormone therapy with Genotropin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees idiopathic short stature.The patient has extreme short stature with a height that is more than 2.25 SDS below normal and an adult height prediction of only 57.5 inches. Although the patient has had normal results on provocative GH testing, the patient meets U.S. Food and Drug Administration criteria for treatment with GH for idiopathic short stature. According to  the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDS below the mean for age or more than two SDS below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two SDS below the mean for age; (4) low serum IGF-1 and/or insulin like growth factor (IGFBP-3); and/or (5) other clinical features suggestive of GH deficiency. The submitted records indicate the patient meets most of the above criteria. For these, reasons the requested growth hormone therapy with Genotropin is medically necessary for treatment of this patients idiopathic short stature. 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 a panniculectomy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees abdominal pannus and are not reconstructive in nature. Findings: The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned. The patient has a significant lower abdominal pannus secondary to weight loss. The patient is noted to have functional impairment related to chronic intertrigo and chronic lower back pain associated with their overlapping lower abdominal skin and pannus. The patient's back pain has been treated conservatively with analgesics.  The patient's chronic intertrigo has been treated with over-the-counter creams, as well as prescription steroid and antifungal creams since May 2017. The patient's condition has affected their ability to ambulate. Photographs show evidence of a large, overlapping, abdominal pannus. The patient has evidence of chronic rashes that are directly related to the overlapping lower abdominal pannus and would be addressed with a panniculectomy. In addition, their chronic low back pain would likely improve with a panniculectomy. Therefore, the requested panniculectomy is medically necessary. Per the submitted documentation, this patients condition constitutes an abnormal structure of the body. The records document a large, overhanging pannus. The patients condition resulted from the treatment of obesity, which is a disease. The requested surgery is likely to improve the patients function. A panniculectomy is likely to improve their chronic rashes and back pain. Additionally, the requested services are likely to result in more than a minimal improvement in the appearance of the patient. Thus, the requested panniculectomy is reconstructive in nature. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial laser hair removal. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria and are not reconstructive in nature. Findings: Facial hair removal is clinically appropriate for treatment of gender dysphoria. The record notes that hormone therapy has not been effective in treating this patients excessive facial hair. Therefore, facial laser hair removal is medically necessary for treatment of this patients gender dysphoria.With regards to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is considered an abnormal body structure. It would be abnormal for a female to have terminal hair on the face. The patients abnormal appearance is the result of gender dysphoria, a disease classified as a disorder. Facial laser hair removal can provide a substantial improvement in the appearance of terminal hair and create a normal appearance to the extent possible. Facial laser hair removal would also provide more than a minimal improvement in the appearance of this patient. For these reasons, facial laser hair removal is reconstructive in nature. 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 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for intensive outpatient psychiatric (IOP) services for treatment of the enrollees eating disorder and gender dysphoria. Findings:  The physician reviewer found that The documentation provided supports the medical necessity of the services at issue in this patients case. The patient continued to be symptomatic. The patient was documented as having persistent depressive and anxiety symptoms.  The patient restricted snacks, complained of nausea and fullness, and was slow to complete meals.  The patient was also noted to have intermittent suicidal ideation and self-harm thoughts. The documentation indicates that as time progressed, the patients symptoms from co-occurring disorders, MDD, PTSD, and gender dysphoria, worsened and the patient was less motivated to engage in treatment.  There was also significant familial conflict, which affected the patients progress in treatment.  At the time of discharge from IOP, it was recommended that the patient engage in higher level of care at a residential treatment facility.  The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth.  The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services. Based on the patients clinical history and the documentation provided, this patient met CASII criteria for intensive outpatient services.  The patients medical condition, in addition to current medical literature, support the treatment at the IOP level of care. Therefore, IOP services were medically necessary for treatment of this patients medical 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 44-year-old female enrollee has requested authorization and coverage for surgery (embolization of bilateral gonadal veins)for treatment of the enrollees pelvic congestion syndrome. Findings:  The physician reviewer found that There is sufficient support in the medical literature supporting embolization of bilateral gonadal veins in the clinical setting of pelvic congestion syndrome. The medical literature indicates that treatment with embolotherapy demonstrates significant improvement in pain levels in patients with chronic pelvic pain caused by pelvic venous congestion. The medical literature supports embolization of gonadal veins as a safe and successful treatment option for this patient. As such, the request for surgery (embolization of bilateral gonadal veins) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested surgery is 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:  One reviewer is board certified in interventional radiology and diagnostic radiology and is actively practicing. One Reviewer is board certified in diagnostic radiology and is actively practicing.  One Reviewer is board certified in surgery and vascular surgery and is 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 reimbursement and prospective authorization and coverage for Gamunex-C solution (intravenous immunoglobulin) 40 g/400 mL, three days every four weeks. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollee who has a history of autoimmune disease.Findings: There is support in medical literature for the medical necessity of the services at issue in this clinical setting. Studies have demonstrated the clinical benefits of IVIG treatments in improving pregnancy outcome and downregulation of the peripheral blood NK cells. Additionally, the medical literature indicates that post-conception IVIG treatment significantly improves reproductive outcomes in women with elevated CD56+ NK cells with pregnancy. According to the submitted clinical information, this patient is diagnosed with elevated level of NK cells and CD19+/5+b-1 cells in the peripheral blood. She is also diagnosed with recurrent pregnancy loss and antiphospholipid antibody disorder.  Based on the documentation provided and the medical evidence, this patient would benefit from continued IVIG treatment.  Therefore, Gamunex-C solution (IVIG) 40 g/400 mL, three days every four weeks were and are medically necessary for the treatment of this patients medical condition.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 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 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 subcutaneous implantable cardioverter defibrillator (ICD). Findings:  Three physician reviewers found that based on traditional risk factors, this patient does not meet the criteria for ICD placement for primary prevention of sudden cardiac arrest. The records do not indicate a family history of sudden cardiac arrest or a maximal wall thickness greater than 3.0 cm. However, based on the totality of the medical records, specifically the cardiac magnetic resonance imaging, which demonstrated a greater than 25% left ventricle scar burden, the patient is at significant risk for sudden cardiac arrest even though he has not met the traditional criteria for prophylactic ICD placement.  The emerging risk factor of extensive myocardial scarring exceeding 15% should be strongly considered. In this case, standard therapy would be watchful waiting and/or medical therapy, which have not been found to be as protective as ICD placement. Accordingly, subcutaneous ICD placement is likely to be of greater benefit for the treatment of the patients medical condition than the available standard therapy. Final Results: 2 of 3 reviewers determined that the requested device is 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 internal medicine with sub-specialty certification in cardiovascular disease 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: An enrollee has requested authorization and coverage for immunotherapy (allergy shots once per week for 52 weeks, two injections per visit). Allergy shots are indicated for persistent symptoms on a seasonal and/or perennial basis and those with an inadequate or partial response to environmental control and medications. Current guidelines recommend skin testing and allergy shots as an effective treatment for allergic rhinitis, asthma and atopic dermatitis. The intervals between maintenance immunotherapy injections generally range from four to eight weeks for venom and every two to four weeks for inhalant allergens but can be advanced as tolerated if clinical efficacy is maintained. In this case, the medical records indicate that the patient is on maintenance therapy. The patients response to immunotherapy, percent improvement and any adverse reactions during build-up are not noted. The maintenance therapy is for inhalant allergies and would typically be every four weeks up to every two weeks if needed. The medical records fail to demonstrate the need for weekly injections during the maintenance phase. As such, the request for authorization and coverage for immunotherapy (allergy shots once per week for 52 weeks, two injections per visit) is not medically necessary.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 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 a similar medical condition.