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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI). Findings:  The physician reviewer found that evidence based medical guidelines do not routinely recommend repeat MRI. The guidelines state that repeat imaging should be reserved when a significant change in symptoms and/or findings are suggestive of significant pathology. A study concluded that radiographs are indicated as part of the initial work-up for all chronic shoulder pain. This patient presents with a history of chronic right periscapular shoulder pain. She had a myriad of other symptoms. Right shoulder clinical findings documented mild right shoulder rotator cuff weakness. A right shoulder MRI was performed with findings of a posterior superior labral tear and a partial thickness tear of the supraspinatus/infraspinatus conjoined tendon. The patient had failed to improve despite extensive conservative treatment. Right shoulder surgery was recommended. As such, the documentation does not present a compelling rationale to support the medical necessity of an additional MRI scan. There has been no change in the periscapular symptoms since her last MRI. Therefore, the requested MRI is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewers 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: Physician 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Technivie 12.5-75-50 mg medication, for quantity of 14 tablets for a 14-day supply. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage. The AASLD/IDSA guidelines recommend that treatment naive genotype 4 patients should be treated with Technivie and ribavirin for 12 weeks. This guideline recommendations is based on the PEARL-1 trial, which demonstrated a 100% cure rate in this population. However, this patients records do not include a documented plan to use ribavirin. Thus, the requested treatment with Technivie for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Expedited Review A male enrollee has requested authorization and coverage for Praluent and Repatha. The Health Plan has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees hyperlipidemia and probable diagnosis of familial hypercholesterolemia. 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. Nature of Statutory Criteria/Case Summary: Repatha and Praluent are PCSK9 inhibitors approved only for patients with heterozygous familial hypercholesterolemia or documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient does not meet these criteria. Based on the records provided for review, the patient presents with hyperlipidemia and is intolerant of statins and Zetia. However, there is no documentation to support a history of homozygous familial hypercholesterolemia, heterozygous hypercholesterolemia, or atherosclerotic heart disease. PCSK9 inhibitors have not been studied in other patient populations such as this patient. Also, current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting. For these reasons, the requested Praluent and Repatha 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: EE requested authorization and coverage for weight loss surgery consultation for gastric bypass. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case. Although this patient is morbidly obese and has a symptomatic ventral hernia that cannot be repaired without substantial weight loss, bariatric surgery has not been determined to be medically necessary. There is no dietary evaluation or psychological evaluation that has documented this patients compliance with necessary lifestyle changes and there is no evaluation of stability from substance abuse. The medical necessity cannot be determined without documentation of a thorough multidisciplinary evaluation. Therefore, the current medical evidence does not support the requested services in this clinical setting.  All told, the requested consultation for gastric bypass surgery is not medically indicated for the 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 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 brand name Prozac 20 mg and Femring 3.5 mg. Findings:  The physician reviewer found that this patients specific menopausal symptoms and the improvement with Femring are not documented. The records do not include discussion of systemic hormone treatment risks and benefits, nor do the records indicate why the patient is not a candidate for other types of hormone replacement, including those on the Health Plans formulary. Per the North American Menopause Society guidelines, use of low-dose intravaginal estrogen does not require additional progestin. The authors also indicate that Estring is considered low-dose intravaginal estrogen therapy, but Femring is not considered in the same category as it delivers systemic levels of estrogen. Accordingly, the requested Femring 3.5 mg is not supported as medically necessary for treatment of this patients medical condition. In addition, the patient has reportedly been stable on brand name Prozac for over 10 years. Although the records indicate that the patient takes Prozac to alleviate symptoms of multiple sclerosis, there is no documentation of the patients specific symptoms of multiple sclerosis that are improved while on the Prozac. The record is also not clear on how the patient is to take the Prozac as the dosage and frequency are inconsistent in the records. All told, the requested Prozac 20 mg is not 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 family practice 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 a computed tomography (CT) scan. Findings:  The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  In this patients case, he had a significant injury, resulting in multiple complex facial fractures.  While strictly speaking his fractures were not involving the base of the skull (as defined as the occipital, temporal, sphenoid, and ethmoid bones), the fractures that he did have were within a very short distance from the skull base.  In addition, he had ethmoid signs which could have been interpreted as a cerebrospinal leak.  These findings, in combination with the headache and sense of feeling slow, are reasonable indications for a CT scan of the brain.  All told, the CT scan performed was medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier Testing performed. Findings:  The physician reviewer found that  while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  Afirma Gene Expression Classifier Testing utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  In sum, Afirma Gene Expression Classifier Testing performed was likely to have been more efficacious than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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: Physician reviewers 1, 2 & 3  are  board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400 mg 100 mg for 12 weeks for treatment of his hepatitis C. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  This applies regardless of fibrosis stage.  Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive, genotype 2 patients.  The medical evidence indicates that a delay in treatment may result in decreased survival. Final Result: The reviewers determined that the requested medication regimen 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing performed for evaluation of his coronary heart disease (CAD). Findings:  Three physician reviewers found that in this circumstance, prevention guidelines for the management of cardiac risk and dyslipidemia have been established. These guidelines are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low density lipoprotein (LDL), high density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Credentials/Qualifications: Reviewers 1, 2, and 3 was board certified in internal medicine with sub-certification in cardiovascular disease 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Viekira XR 8.33-50 mg tablet daily for 12 weeks. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  Per the guidelines, treatment naive genotype 1b patients should be treated with Viekira XR for 12 weeks. The medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  The guidelines also cite data showing increased survival with earlier treatment. Final Result: The reviewers 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 physician reviewer number one is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Standard Review Fulfills requirements of (1374.33) (h)(1)(D)A transgender male enrollee has requested authorization and coverage for phalloplasty surgery. The Health Plan has denied this request indicating that the requested services are not medically necessary and are not reconstructive in nature for treatment of the enrollees gender dysphoria.  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. Nature of Statutory Criteria/Case Summary: The submitted documentation demonstrates the medical necessity for the requested services in this clinical setting. The patient is well-documented to have gender dysphoria. Thus, his external anatomy should be more consistent with a male than a female. The patient has undergone bilateral mastectomy as part of his surgical transition to a male.  He is noted to have begun hormonal therapy with testosterone treatment. Although he may have had some gaps in his testosterone therapy, he has been evaluated by mental health providers who have assessed him to be a good candidate for phalloplasty.  In this patients case, the medical necessity for the requested services has been adequately supported in the documentation provided. This patient began hormonal therapy in 2009 and has taken irreversible steps towards his transition. Therefore, the requested phalloplasty is medically necessary for the treatment of this patients gender dysphoria.With regard to whether the requested services are considered reconstructive in nature, the submitted documentation demonstrates that the patients condition constitutes an abnormal body structure. Based on the patient's diagnosis of gender dysphoria, lack of male genitalia should be considered abnormal. Is the abnormal structure of the body caused by any of the following: congenital defects, developmental abnormalities, trauma, infection, tumors or disease? Yes, the abnormal structure is due to the fact that the patient has a diagnosis of gender dysphoria and has not had adequate development of male genitalia. Is the requested surgery being performed to do either of the following: improve function or create a normal appearance to the extent possible? Yes, phalloplasty would help to create a more normal appearance. Does the surgery provide more than a minimal improvement in the appearance of the patient? Yes, the proposed phalloplasty would be expected to provide significant improvement in the patients appearance. 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The spouse of the deceased enrollee has requested reimbursement for the gene testing for evaluation of his pancreatic endocrine carcinoma. Findings:  Two physician reviewers found that molecular profiling of an individuals cancer cells is an assay of genomic and molecular abnormalities. The goal of this assay would be to identify a target at which a specific treatment could then be offered. Although of scientific interest, as yet there is a lack of convincing evidence that the assay adds to the decision making ability to improve patient outcome. There are a variety of non-randomized studies exploring the value of molecular profiling but have not been convincing as to the superior efficacy of these assays.  Researchers noted the ongoing research but reported the serious limitations of these studies. A recent randomized trial, did not demonstrate significant clinical benefit when choosing therapy based on molecular targets. As such, there is a lack of robust medical studies to indicate the clinical benefit of this assay in this clinical setting. Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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.