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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a hair transplant. The World Professional Association for Transgender Health (WPATH) notes, Non-genital surgical procedures are routinely performed.these surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals. Adjusting the hairline is an essential part of facial feminization surgery. Scientists noted that hair transplant is an essential part of facial feminization surgery and reported, After the forehead, the hairline pattern is the second most important feature of gender identification within the upper third of the face. The combined evaluation of these two features should be a basic premise of facial feminization surgery. The medical evidence supports the requested services for the treatment of this patient with gender dysphoria. Therefore, a hair transplant is 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 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 patient has requested authorization and coverage for a consultation with a dermatologist. The National Comprehensive Cancer Network (NCCN) guidelines for melanoma recommend regular examinations depending on a patients disease course. In this case, the patient has a history of an atypical nevus that required a re-excision of the lesion to ensure removal in its entirety. This type of atypical nevus is considered severely atypical and treated similarly to a melanoma in situ. Given the patients history of an atypical nevus, annual consultation with a dermatologist is medically necessary for skin screening and prevention. Therefore, consultation with a dermatologist is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy (PBRT) (CPT 77520 x 30), (CPT 77522 x 30), (CPT 77523 x 30), (CPT 77525 x 30) and (CPT 76498). Current evidence does not endorse the routine use of PBRT in the treatment of Hodgkin lymphoma. The standard treatment of Hodgkin lymphoma is with photon techniques utilizing intensity modulated radiation therapy and image guidance using breath hold techniques, which can minimize dose to the heart and lungs. There is insufficient data to suggest that PBRT would significantly improve the sparing of the spinal cord, heart, and/or lungs compared to standard photon techniques. In the majority of cases, IMRT is able to achieve an acceptable cardiac and lung dose. In this case, there is a lack of evidence submitted indicating that the use of standard photon techniques would exceed standard dose metrics. Therefore, PBRT (CPT 77520 x 30), (CPT 77522 x 30), (CPT 77523 x 30), (CPT 77525 x 30) and (CPT 76498) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested proton beam radiation therapy (PBRT) (CPT 77520 x 30), (CPT 77522 x 30), (CPT 77523 x 30), (CPT 77525 x 30) and (CPT 76498).  is not 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 not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Coflex interlaminar stabilization device (CPT 22867). Based on the documentation provided for review, this patient meets the criteria for surgical intervention. He has medically refractory lumbar radiculopathy due to a large lumbar disc herniation. The records document failure of non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and injection therapy. His providers initial plan to recommend a microdiscectomy at the affected level is the standard of care surgical approach for the treatment of lumbar radiculopathy caused by a disc extrusion. In addition, the records suggest that the patients symptoms have meaningfully improved from 9/10 to 2/10 on the pain scale. Considering this improvement, a repeat magnetic resonance imaging (MRI) is needed to determine if the disc herniation is still present and requires surgical intervention. Moreover, there is a paucity of data in the peer-reviewed medical literature comparing lumbar microdiscectomy to microdiscectomy plus Coflex for the treatment of lumbar radiculopathy from a lumbar disc herniation. Two non-randomized studies compared lumbar microdiscectomy to microdiscectomy plus Coflex and reported incongruent findings. One study suggested improved outcomes after seven to nine months of follow-up with decompression plus Coflex while the second study countered these findings. Overall, there are insufficient data supporting the utilization of the Coflex device in conjunction with lumbar decompression versus lumbar decompression alone for lumbar stenosis with or without stable grade 1 spondylolisthesis. In sum, the requested Coflex interlaminar stabilization device (CPT 22867) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Coflex interlaminar stabilization device (CPT 22867) is not 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 not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurological surgery 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees representative has requested reimbursement for Guardant360 liquid biopsy gene assays. Molecular diagnostic studies in non-small cell lung cancer are considered within the standard of care based on current publications and guidelines. In addition, numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) strongly advises broader molecular profiling with the goal of identifying driver mutations for effective therapies, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is key for the improvement of care in patients with non-small cell lung cancer. Testing of lung cancer specimens for specific alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Integration of molecular genetic testing into the routine management of patients with stage IV non-small cell lung cancer demonstrates a marked increase of the detection of therapeutically targetable mutations and improved delivery of molecularly guided therapy. This patient with metastatic lung cancer underwent Guardant360 liquid biopsies less than one year apart.  It is standard practice to reevaluate a molecular panel with recurrences to see if the patients tumor has developed any new actionable mutations. All told, the Guardant360 liquid biopsy gene assays were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the Guardant360 liquid biopsy gene assays were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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 reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for the medication Lupron Depot injections. The patient has been diagnosed with premenstrual dysphoric disorder. She was seen by her gynecologist for reported symptoms of depression, anxiety, anger, compulsive behavior, and difficulty concentrating. It was noted she is followed by a psychiatrist and a therapist. The patient has tracked her menstruation cycle and reports that the change in behavior, mood, and cognition happens the week before she gets her period. She has been treated with oral contraceptive pills in the past, but developed psychiatric symptoms and the contraceptive pills were discontinued. She has also tried antidepressant medications, which she reports did not help. Lupron Depot injections were prescribed and her gynecologist has recommended the Lupron Depot be given monthly. In women with severe symptoms who have not responded to or cannot tolerate Selective Serotonin Reuptake Inhibitors (SSRIs) or oral contraceptives, gonadotropin-releasing hormone agonist therapy (GnRH) is the next step. A review of the current literature shows the first demonstration of benefit of medical oophorectomy with a GnRH agonist in the treatment of premenstrual syndrome was made in a crossover study of eight patients. This finding has subsequently been replicated by several other investigators. Due to the severity of this patient's symptoms, and as supported by current medical literature, treatment with Lupron Depot is medically necessary to treat the patients medical condition. Result: The reviewer determined that the Lupron Depot injections are medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in obstetrics and gynecology as well as reproductive 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for Ehlers-Danlos Syndrome Next Generation Sequencing (NGS) Panel (CPT 81408). As noted by the treating provider, the patients presentation is consistent with hypermobile Ehlers-Danlos syndrome, or may fit within a hypermobility spectrum disorder. However, there is no molecular testing to confirm these diagnoses. The provider noted facial and skin findings that could be consistent with vascular Ehlers-Danlos syndrome including a thin face with thin, pinched nose, hollow cheeks, and visible veins. Vascular Ehlers-Danlos syndrome has a risk of serious complications. When considering a diagnosis of vascular Ehlers-Danlos syndrome, testing for this via COL3A1 sequencing, deletion, and duplication analysis is essential to confirm or rule out the diagnosis. This patient does not have findings concerning for other forms of Ehlers-Danlos syndrome. Thus, testing for all of the genes included in the Ehlers-Danlos syndrome NGS panel is not warranted. Therefore, the COL3A1 gene sequencing, deletion, and duplication analysis portion of the Ehlers-Danlos Syndrome NGS Panel (CPT code 81408) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the COL3A1 gene sequencing, deletion, and duplication analysis portion of the Ehlers-Danlos Syndrome NGS Panel (CPT code 81408) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that a portion of the requested services 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 partially overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in genetics and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy twice a week, or in the alternative physical therapy once per week. The records provided for review document that this patient has undergone extensive physical therapy for her knee condition. Physical examination notes reveal a lower extremity functional scale score of 50/80, which improved from 58/60 on prior testing. Improvement was noted in knee extension from 4-/5 to 3+/5 on the left, with the remainder of range of motion and gross muscle tests of the lower extremity unchanged since prior assessment. The patient has participated in extensive physical therapy, she has received thorough instruction on her condition, and she has been compliant in a home exercise program. The records do not demonstrate that the skills of a physical therapist are required to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design or deliver a program to maintain the patients current condition or to prevent or slow further deterioration. All told, the requested physical therapy twice a week or in the alternative physical therapy once per week, 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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 patient has requested reimbursement and prospective authorization and coverage for Long-term acute care hospital (LTACH) services. LTACH level care is intended for patients who require care that is more medically complex than can be provided at lower levels of care, such as inpatient rehabilitation, or SNF levels of care. LTACH level of care includes provision of chest tubes, extensive wound care, stable cardiac drips, multiple intravenous antibiotics, hemodialysis, prolonged intravenous therapy, total parenteral nutrition, tracheostomy care, ventilator weaning, and frequent imaging and laboratory testing. In general, more than one of these treatments is being provided at the LTACH level of care. There should also be documentation of prior treatment failure at lower levels of care or reasonable expectation of treatment failure at lower levels of care. This patient had a persistent ulcer, complicated by osteomyelitis that failed initial management with hospitalization, SNF care, and outpatient wound clinic follow-up. She was transferred to an LTACH for further care given her multiple concomitant complex medical issues having failed less intensive therapy. By the first date of denial, she had completed her antibiotics and there was no indication that her right heel wound had worsened or required acute hospital care. She was stable on chronic hemodialysis and required only maintenance management. She has other longstanding issues such as impaired function due to multiple strokes, depression, hypertension and diabetes. However, there is no evidence of active issues that require acute hospital level of care. Her laboratory studies have stabilized, with stable anemia at her goal hemoglobin level, resolved reactive thrombocytosis, and stable renal and hepatic profiles. The records indicate that she is on hemodialysis and has a persistent wound, but these stable issues are chronic and do not require LTACH level of care. There are no more complex medical treatments, or need for frequent testing beyond maintenance monitoring. Renal service has recommended weekly laboratory testing. All told, the LTACH services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation 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 patient been diagnosed with bilateral knee degenerative joint disease with underlying advanced patellofemoral chondromalacia. The patient received Monovisc injections to bilateral knees in August 2019. The patient reported slow improvement due to prior viscosupplementation injections with less pain and sensitivity. The patient was noted to have had improvement due to prior viscosupplementation injections. The patient reported knee pain, left greater than right. The provider noted x-rays demonstrated some joint space narrowing and bony sclerosis. The patient has requested authorization and coverage for viscosupplementation (hyaluronan) injections in both knees. The Health Plan denied the request and reported the requested service is not medically necessary for the treatment of this patient. At issue in this case is whether viscosupplementation (hyaluronan) injections in both knees is medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of lasting benefit from prior viscosupplementation injections. The alternative is bilateral total knee arthroplasties. The medical evidence supports the requested service in this clinical setting. Therefore, viscosupplementation (hyaluronan) injections in both knees are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 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.