Persius/hicric huggingface dataset:
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 brand name Minivelle transdermal patch. As noted by the North American Menopause Society (NAMS), there are many options for estrogen for hormone replacement that have been demonstrated in the clinical studies to be equally effective. Transdermal estrogen is reported to have the lowest potential for increased risk of thrombosis, which the patient noted is a concern given her treatment with a blood thinner (Bergendal, et al.). The patient reports that she can tolerate brand name Minivelle, but other hormone replacement therapies have caused side effects. However, there are alternative transdermal estrogens available for treatment of this patient. In addition, there are no primary source treatment records to document that the patient has completed an adequate trial to, or has been intolerant of, other estrogen options available for hormone replacement in the setting of menopause. All told, the brand name medication Minivelle transdermal patch was not and is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was not and 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 obstetrics and gynecology 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 Durolane injection in the right knee. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. Guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, there is documentation of osteoarthritis of both knees, right greater than left. Conservative treatment, including NSAIDs, opioid medications and a cortisone injection, have been tried. Arthroscopic surgery was also tried and failed. There is sufficient support for the requested service in this clinical setting. Therefore, the requested Durolane injection in the right knee is 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral mastectomy and chest reconstruction surgery. Findings:  The physician reviewer found that he World Professional Association for Transgender Health (WPATH) states, Chest surgery in female-to-male patients could be carried out earlier [than 18], preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescents specific clinical situation and goals for gender identity expression. Olson-Kennedy and colleagues report that chest surgery is an effective treatment of gender dysphoria in minors, stating, Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. Given these findings, professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age. In this case, while the patient is noted as having an episode of suicidality in November 2021, such an episode is not a permanent bar to treatment and the submitted records include a letter from the patients psychologist reporting that the patient's mental illness is now relatively well-controlled. Given that the patient has a long-standing identity as male and has been on testosterone for over a year, the requested services are medically indicated. Therefore, bilateral mastectomy and chest reconstruction surgery are medically necessary to promote physical and mental health and efficiency and to ameliorate behavioral conditions. 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 endoluminal ablation. The records provided for review indicate that this patient presents with venous insufficiency. Following physical evaluation and imaging, the patients provider charted that the patients symptoms are due to residual reflux in the saphenous veins. There is also adequate documentation that the patients symptoms are interfering with her ability to perform activities of daily living. In addition, there are imaging reports demonstrating arterial perfusion to the lower extremities bilaterally. There is no evidence of deep vein thrombosis (DVT). The provider has recommended endoluminal ablation of the patients venous reflux. Obi and colleagues assessed 2,661 veins in 1,803 limbs, in 1,406 patients who were treated for varicose vein disease. The authors noted that, Endovenous treatment of axial reflux was the preferred treatment in 89.1%, divided largely between radiofrequency ablation (55.2%) and endovenous laser ablation (33.9%). The authors concluded that patients reported improvements in swelling, itching, appearance, and work impact, as well as reduced sensations of heaviness, aching, and throbbing. Given this support, the requested endoluminal ablation of the right great saphenous vein is medically necessary for 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 general surgery with subspecialty certification in vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for compression garments. The records provided for review document that this patient established care with a hematologist following an acute deep vein thrombosis (DVT). The patients provider recommended treatment with Xarelto for three to six months as well as evaluation with multiple imaging studies to ensure DVT resolution. The patient underwent imaging as well as treatment with Xarelto, but she continued to experience pain and intermittent swelling. As part of the patients assessment, the providers diagnostic impression included post-thrombotic syndrome. The provider also recommended treatment with compression garments. Cosmi and colleagues reported that post-thrombotic syndrome is diagnosed in 40-50% of patients who are diagnosed with DVT. The authors reviewed multiple studies and reported that that thigh-length gradient compression stockings with exercise and anticoagulation are recommended for management of patients with post-thrombotic syndrome. Given this support, the requested compression garments are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intravenous immunoglobulin (IVIG) Octagam 40 gm daily x four days, then 40 gm daily for two days every four weeks for 12 weeks. Findings:  The physician reviewer found that Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a chronic progressive or relapsing and remitting disease that can cause weakness and sensory loss. CIDP tend to respond well to therapies that reduce inflammation. As noted by Oaklander and colleagues, IVIG and corticosteroids remain first-line treatments for patients with CIDP. According to the Evidence-based Guideline by the American Academy of Neurology (AAN), IVIG is effective and should be provided in the long-term care of patients with CIDP (Patwa, et al.). The European Federation of Neurological Societies (EFNS) and Peripheral Nerve Society (PNS) have identified pure sensory CIDP, or chronic immune sensory polyradiculopathy (CISP), as a condition that presents with sensory neuropathy, ataxia, and normal nerve conduction from selective sensory nerve root inflammatory demyelination (Doneddu, et al.). According to the EFNS/PNS, IVIG therapy has been found to be safe and effective in the treatment of patients with CISP as well as in patients with typical CIDP. In this case, the patients condition is consistent with progressively worsening CISP. The records document that the patient is experiencing symptoms that are interfering with her ability to perform activities of daily living. Based on the AAN guidelines and current medical literature, the planned regimen of IVIG is supported as appropriate for treatment of this patients CISP. Therefore, the requested IVIG Octagam 40 gm daily x four days, then 40 gm daily for two days every four weeks for 12 weeks is medically necessary for 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 neurology 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 bilateral occipital nerve blocks. Findings:  The physician reviewer found that patients provider reports a history of occipital based headaches with physical examination confirming tenderness over the occipital area reproducing the headaches. The patient has been treated with conservative care including chiropractic care, heat, physical therapy, and medication management without adequate improvement in her headaches. There is adequate evidence in the peer-reviewed medical literature to support treatment with occipital nerve blocks for this patients occipital neuralgia given the failure of symptomatic control with standard available therapies. A review by Pan and colleagues on the treatment of patients with occipital neuralgia found that, The occipital nerve block is considered the first-line in a minimally invasive intervention, but the duration of relief may be short-term. Barmherzig and colleagues evaluated the current evidence and recommendations for the diagnosis and management of occipital neuralgia and noted that, Anesthetic block of the greater and/or lesser occipital nerves are often used both diagnostically and therapeutically. The authors concluded that, Anesthetic nerve blocks may have a dual role in both supporting diagnosis and providing pain relief. Given these findings, the requested bilateral occipital nerve blocks are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for 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 anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain medicine 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for apolipoprotein testing as a component of a NASH FibroSURE test panel. Medical literatures note that chronic hepatitis B may result in complications of severe liver disease and in cirrhosis. Medical literatures explain that cirrhosis is the final outcome of all chronic liver disease, and that management of cirrhosis requires specific therapy and monitoring for complications such as hepatocellular carcinoma surveillance with ultrasound and alpha-fetoprotein every six months, and monitoring for portal hypertension, esophageal varices, and hepatic encephalopathy. Researchers report that fibrosis blood tests have been validated in chronic hepatitis C and that the diagnostic performance of blood tests in hepatitis B. Serologic fibrosis testing such as FibroSURE reliably determines the presence of advanced fibrosis and cirrhosis in a variety of liver diseases, including Hepatitis B. Researchers report that although liver biopsy has been considered the gold standard for staging liver fibrosis, it is an invasive technique and subject to sampling errors and significant intra- and inter-observer variability. Risks from liver biopsy may include bleeding and bile duct injury. Therefore, apolipoprotein testing as a component of a NASH FibroSURE test panel was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the apolipoprotein testing as a component of a NASH FibroSURE test panel was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for custom orthotics for both feet. As discussed in the peer-reviewed medical literature, treatment with custom orthotics can help correct painful biomechanical abnormalities in the feet. Carr and colleagues noted that there is a lack of large, prospective studies that compare the natural history of idiopathic, flexible flat feet throughout development in response to various treatments. The authors found that, Painful flexible flatfoot may benefit from orthopedic intervention, such as physical therapy, bracing, or even a surgical procedure. This patients records document substantial bilateral leg and foot pain. The patient was found to have a pes planus foot structure, significant subtalar joint valgus bilaterally, anterior break of the cyma line, and decreased calcaneal inclination angle. The patient has experienced prior improvement with custom orthotics, which have been used since 2017. The provider reported that the patients current custom orthotics are worn out. Given this patients pes planus foot structure and subtalar joint valgus with bilateral leg and foot pain, as well as x-ray findings of calcaneal inclination angle decrease and anterior break of the cyma line, treatment with custom orthotics is appropriate. Each of these findings can lead to significant stress on the plantar fascia, posterior tibial tendon, Achilles tendon, and multiple other ankle and foot ligaments. Orthotics will help hold the patients foot in a neutral position, reestablish an arch, reduce the ability of the foot and ankle to undergo excessive range of motion, and allow for a pain-free ambulation. For these reasons, the requested custom orthotics for both feet are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is a licensed D.P.M., board certified in podiatric surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a DecisionDx-Melanoma test. The use of gene expression profiling (GEP) testing according to specific American Joint Committee on Cancer (AJCC) melanoma stage, before or after sentinel lymph node biopsy (SLNB), requires further prospective investigation in large, contemporary data sets of unselected patients. Prognostic GEP testing to differentiate melanomas at low-risk versus high-risk for metastasis should not replace pathologic staging procedures. Moreover, since there is a low probability of metastasis in melanoma at this stage and a higher proportion of false-positive results, GEP testing should not guide clinical decision-making in this subgroup. Therefore, DecisionDx-Melanoma test was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the DecisionDx-Melanoma test at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Shingrex shingles vaccination. The submitted documentation does not support the medical necessity of the requested medication. Varicella-zoster virus (VZV) infection may cause both a primary infection known as chickenpox and a reactivated infection, from latent VZV in nerve cells, known as Herpes zoster or shingles.  The U.S. Food and Drug Administration (FDA) approves the use of Shingrex for the prevention of herpes zoster, or Shingles, in adults aged 50 years or older or in adults aged 18 years or older with immunodeficiency or immunosuppression caused by disease or therapy. Medical literatures note that the vaccine consists of varicella-zoster virus glycoprotein E (gE). In this case, the records reflect that the patient is 46 years of age. The records do not document that the patient is immunocompromised, or that her provider is planning to prescribe medications that will cause the patient to become immunocompromised. While the records note that the provider has prescribed Acyclovir for the patients previous infections of recurrent zoster, there is no documentation of a physical examination of the skin that has confirmed these infections. Therefore, a Shingrex shingles vaccination is not medically necessary for the treatment of this patient.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 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.