Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left knee makoplasty. The Health Plan has denied this request indicating that the requested services are investigational for the treatment of the enrollees left knee pain.Findings:  Nationally recognized evidence based medical guidelines do not recommend makoplasty knee arthroplasty based on lack of evidence showing improved clinical outcomes. Further research is needed to determine if this technological advancement will translate into improvements in longevity and clinical outcomes. At present, few studies have assessed and compared the survivorship and functional outcomes of robotic-assisted surgery to conventional knee arthroplasty. This patient presents with persistent left knee pain. Records documented conservative treatment to include corticosteroid injections, activity modification, and medications, without sustained improvement. Clinical examination findings have documented medial joint line tenderness, varus alignment, and pseudolaxity on varus/valgus stress. There is radiographic evidence of bone-on-bone articulation with periarticular osteophytes to the medial compartment, moderate to severe degenerative changes to the patellofemoral compartment, and mild to the lateral compartment. The patient has been recommended for a bicompartmental knee replacement using the makoplasty system. However, current evidence based medical guidelines and peer-reviewed literature do not support the use of robotic assisted surgery over conventional knee replacement based on lack of evidence for improved outcomes. As such, a left knee makoplasty is not likely to be more effective for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  All three reviewers are board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Grafix core, grafixpl core, Grafix Prime, grafix pl prime, and application for treatment of the enrollees burn wound. Findings:  The physician reviewers found that Grafix has been mostly used to assist in healing with chronic wounds such as diabetic foot ulcers. The use of Grafix in burn treatment is more limited and these products have not become the standard of care in this clinical setting. The patient had a chronic wound from a full-thickness burn sustained three months previously. The medical history received for review indicated that no debridement of the burn had been performed except for the application of enzymatic ointment because of patient sensitivity. A formal wound debridement was performed after infiltration of local anesthetic, and slough was debrided. The wound that resulted from the debridement of the full-thickness burn was effectively an acute wound. The use of Grafix to potentially augment wound healing is not supported by large studies and its use for an acute full-thickness wound following debridement remains of unproven efficacy at this time. In sum, Graphix core, grafixpl core, Grafix Prime, grafix pl prime and application are not likely to be more efficacious than the standard techniques for the treatment of this patients wound.Final Result: Two of the three reviewers determined 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:  All three reviewers are board certified in plastic surgery 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: The transgender male enrollee has requested authorization and coverage for consultation with a plastic surgeon regarding a bilateral mastectomy. The Health Plan has denied this request indicating that the requested services are not medically necessary for the evaluation of the enrollees gender dysphoria. Findings: Based on the documentation provided, the patient has gender dysphoria and is transitioning to the male gender. He has lived as a male for many years and has been undergoing prescribed hormonal therapy. The patient binds his chest, which is supportive of a female appearance. He has evidence of female breasts that are considered abnormal for a male. He continues to have gender dysphoria related to breast development. Based on the patients gender dysphoria and identification as a male, a normal appearance of the breasts for a male is the goal. The medical documentation is supportive of an initial consultation with a plastic surgeon who is qualified to further evaluate his gender dysphoria and possible role for surgical intervention. Therefore, a consultation regarding a bilateral mastectomy is medically necessary for the evaluation of this patients gender dysphoria. Final Result: The reviewer determined that the requested services are medically necessary for the evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for inpatient eating disorder hospitalization services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee who has a history of eating disorder.Findings: The documentation submitted supports the medical necessity for the services at issue in this patients case. The patient remained focused on losing weight and the number of calories she consumed. The patient struggled with meal compliance. Her weight was documented as 81.6 pounds with a body mass index of 16.7. 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 (AACAP, 2014). 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 this patients clinical history provided and the documentation as outlined above, on 2/20/18 through 2/28/18, the patient met CASII criteria for level 6 secure 24 hour services with psychiatric management. The patients clinical status, in addition to current medical literature, support that the treatment at the inpatient level of care from 2/20/18 through 2/28/18 was medically necessary for this patient (American Academy of Child and Adolescent Psychiatry CASII; Hergenroeder et al; Morris et al).  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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization psychiatric level of care. The submitted documentation supports the medical necessity of the services at issue. This patient had a prominent addictive illness burden. He had an early age of onset and had a history of significant substance abuse as a young adult. His drug use led to health issues, family distrust and relationship distress. He had previously received treatment in at least the residential and outpatient settings. Per the records, the treatment in dispute successfully facilitated transition to less restrictive programming in the community. Considering the severity of this patients illness burden and his prior treatments, partial hospital services were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards. Additionally, the services at issue were reasonably expected to improve his condition and prevent a more serious episode of illness. Therefore, partial hospitalization psychiatric level of care was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry 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 a seven-year-old female enrollee has requested reimbursement for individual speech therapy services, including augmented alternative communication (AAC) therapy, and feeding therapy services. As noted by a study, patients with 1p36 deletion syndrome greatly benefit from enrollment in a personalized rehabilitation program with attention to motor development, cognition, communication, and social skills. Speech and language delays in 1p36 deletion syndrome are common, with up to 40% of patients reported to have complex speech difficulties. Given that the age of verbal speech onset is significantly delayed, progress can often be slow (a study). It is for this reason that long term speech therapy is recommended. According to this patients speech re-evaluation, the patient has made excellent progress based on standardized test scores. Since starting speech therapy, the patient has improved from non-verbal to vocal, and is using her voice to gain attention and demonstrate desires as well as reject objects and activities. Overall, the patients speech therapy records indicate slow, steady progress, which is typical in this condition. All told, the individual speech therapy services, including AAC therapy, and feeding therapy services provided were medically necessary for treatment of this patients medical condition. All told, the speech therapy services provided 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 pediatrics with sub-specialty certifications in neurodevelopmental behavioral pediatrics and genetics 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 patient has requested authorization and coverage for Mavyret 100-40 mg for eight weeks. The submitted documentation supports the medical necessity of the requested medication regimen. 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 nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret 100-40 mg eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg for eight weeks is medically necessary for this patient.Final Result: The reviewer 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret 40-100 mg, three tablets daily for eight weeks. The submitted documentation supports the medical necessity of the requested medication regimen. 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 nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1b patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials showing high cure rates, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage.  Guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 40-100 mg, three tablets daily for eight weeks is medically necessary for this patient.Final Result: The reviewer 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret . The submitted documentation supports the medical necessity of the requested medication regimen. all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage.  Mavyret  is medically necessary for this patient.Final Result: The reviewer 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Repatha 140 mg/mL injections twice per month. The submitted documentation supports the medical necessity of the requested medication. Based on the records provided, the patient has documented obstructive coronary disease, hyperlipidemia, and an intolerance to statin therapy, such as (Lipitor and Crestor), as well as ezetimibe. Studies show that Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 inhibitor that has been approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of low-density lipoprotein cholesterol. This patient fits the latter criteria since this patients low-density lipoprotein level is elevated above goal and is unable to tolerate statins or ezetimibe. In this clinical setting, proprotein convertase subtilisin/kexin, type 9 inhibitors have been shown in randomized and prospective trials to be safe and effective in lowering cholesterol and associated with improved cardiac outcomes. Therefore, the requested Repatha 140 mg/mL injections twice per month is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for proton beam radiation therapy. Given the proximity to the heart, the exposure could cause long-term cardiopulmonary complications. Based on long-term follow-up in patients treated for Hodgkins disease with radiation, mediastinal radiotherapy significantly increases risks of myocardial infarction, congestive heart failure, and valvular disorders (Aleman, et al). Proton beam radiation therapy for the treatment of thymoma has been shown to be safe and effective (Vogel, et al). Accordingly, the proton beam radiation therapy provided was 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 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:  One reviewer is board certified in radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for LINX Reflux Management System for the treatment of the enrollees medical condition. Findings:  The physician reviewers found that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX, both alone and in comparison to current GERD therapies remains to be determined. Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Adverse events, such as erosion through the esophagus have been reported in the period after the U.S. Food and Drug Administration approval. One peer-reviewed journal published a letter stating that there are 11 reports of endoscopically confirmed LINX erosion through the esophagus in the publicly accessible U.S. Food and Drug Administrations Adverse Events database. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. In this case, the available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial than standard treatment, surgical fundoplication. The American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. For these reasons, LINX Reflux Management System is not likely to be more beneficial than any available standard therapy for the treatment of this patient.Final Result: The 2/3 reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers all 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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.