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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the removal of tissue from the breasts performed for treatment of the enrollees gynecomastia. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the procedure at issue. The patients pain and discomfort is not adequately supported in the medical documentation as likely due to distention and tightness from hypertrophied breast. In addition, the patients grade of gynecomastia is not adequately defined and photographs were not provided for review. The records do not demonstrate a concern for possible malignancy based on examination detail and other results. Other possible causes had not been sufficiently evaluated, including relevant laboratory studies and endocrine work-up. Therefore, the removal of tissue from the breasts performed has not been established as medically necessary for treatment of the patients. Final Result: The reviewers determined that the procedure at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for OxyContin 15 mg, twice daily for treatment of the enrollees knee pain. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  Per the records, non-opioid treatment options have not been exhausted in this case.  The records do not document that behavior therapy has not been discussed or completed despite significant research to support its use.  Additionally, the records indicate that tolerance has taken place since the start of the narcotics.  Dose escalation is not a long-term plan, but a short-term plan for the treatment of tolerance.  Per the literature, there is the possibility of opioid induced hyperalgesia in this setting.  In this patients case, there is no clear objective functional goals for the additional opioids being prescribed.  For all these reasons, the requested OxyContin 15 mg, twice daily is not medically necessary for 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 physician reviewer is board certified in anesthesiology with sub-specialty certification in pan 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 parent of an enrollee has requested authorization and coverage for neuropsychological testing for evaluation of the enrollee, who has been diagnosed with attention deficit/hyperactivity disorder. Findings:  The physician reviewer found that there is sufficient support for the requested services in this patients case.  This patient has been diagnosed with attention deficit/hyperactivity disorder, but there is also concern for autism spectrum disorder because of his behaviors, pragmatic speech deficits, and lack of social skills.  It can be difficult to differentiate between these two neurologic disorders because of commonalities in clinical presentation.  Special training is essential to make the appropriate diagnosis because management of the two disorders can be quite different.  The impact of inaccurate diagnosis and management can have lifelong consequences. Given the extent of this patients neurologic challenges and uniqueness, neuropsychological testing is medically necessary and would be considered standard of care.  Final Result: The reviewer determined that the requested services are 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 pediatrics 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 Farxiga 5 mg tablets for treatment of the enrollee, who has been diagnosed with diabetes. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Farxiga is a member of a relatively new class of diabetes medications, subtype 2 sodium-glucose transport protein (SGLT2) inhibitors.  The primary mechanism of action of this group of agents involves decreasing renal glucose reabsorption, which results in enhanced urinary glucose excretion, thereby leading to reductions in plasma glucose and hemoglobin A1C concentrations.  Studies have shown glycemic control benefits, weight reduction, and systolic blood pressure lowering with monotherapy as well as in combination with other anti-hyperglycemic agents.  Many providers are currently prescribing SGLT2 inhibitors for diabetic patients, and it has been recommended by numerous medical organizations as part of a recommended regimen for treatment of diabetes.  While this patient may benefit from treatment with a medication from this class of drugs, there is a lack of evidence which supports the benefit of Farxiga over another SGLT2 inhibitor.  It is medically appropriate that this patient first try a formulary alternative.  All told, Farxiga 5 mg tablets are not medically indicated 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 with sub-specialty certification in endocrinology, diabetes and metabolism 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 authorization and coverage for implantation of a hypoglossal nerve stimulator for treatment of the enrollees obstructive sleep apnea (OSA). Findings:  2/3 of the physician reviewers found that review of the current literature indicates that use of hypoglossal nerve stimulation in treatment of OSA shows promise. However, criteria for the use of this therapy includes that patients have moderate to severe OSA with an AHI between 20 and 60, BMI of less than 32, and failure of trial of CPAP therapy. This patient has an AHI of 76.7 which is greater than the U.S. Food and Drug Administration (FDA) criteria of less than 60 and greater than 50, which is used for most study criteria. In addition, the medical records provided do not demonstrate the patient has failed treatment with standard therapies including CPAP. As such, this mode of treatment is not medically indicated for this patient. Overall, there remains a need for further study with comparison of outcomes between hypoglossal nerve stimulation and standard CPAP and surgical therapies. For these reasons, the requested implantation of a hypoglossal nerve stimulator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the requested service is 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 number one is board certified in otolaryngology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in sleep 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.Physician reviewer number three is board certified in otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a continuous glucose monitoring (CGM) device for treatment of the enrollees diabetes.  Findings:  The physician reviewer found that the American Association of Clinical Endocrinologists and American College of Endocrinology advocate expanding the use of CGM in the management of diabetes, stating that CGM use is shown to improve glucose control and reduce hypoglycemic events, and therefore has the potential to reduce the risk of acute and chronic complications of diabetes.  In this case, the patient is using multiple injections of insulin, and self titrates his meal boluses. However, he has had significant hypoglycemia with unawareness which puts him at risk for vision changes, energy drop, mental status changes and possible coma. Therefore, without the benefit of CGM, the patient protects himself by keeping glucose levels high, which in turns puts him at risk of long-term diabetes related complications. Even though he has a diagnosis of type 2 diabetes, he is likely insulin deficient and must be managed in the same way that a patient with type 1 diabetes should be managed. The records show his fasting glucose levels have been consistently high, which makes the patients normal C-peptide inappropriate for the level of hyperglycemia and insulin resistance consistent with insulin deficiency. The patient is compliant with therapy, and is willing to be under better control with CGM. Thus, CGM will allow the patient to make adjustments to therapy with avoidance of hypoglycemia. Final Result: The reviewer determined that the requested device is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 facial feminization treatment of the enrollees gender dysphoria. Based on the entirety of the medical documentation provided for this review, the requested services are not medically necessary and are not reconstructive in nature. The medical literature supports facial feminization surgeries which can include forehead remodeling, rhinoplasty, thyroid chondroplasty, and voice alteration procedures for treatment of gender dysphoria. However, in this patients case the submitted documentation does not support a typical functional deficit for each of the requested services. A formal examination was not documented. In addition, based on the submitted photographs, the patient has minimal forehead prominence, mildly prominent brows and mild ptosis which could be consistent with a relatively normal female appearance.  The appearance of the patients forehead and brow is not necessarily gender specific. Further, details regarding the patients lower face, chin, and nose are not documented in the records provided. Based on the submitted photographs, the patients lower face, chin and nose appears consistent with a relatively normal appearance and not specifically gender related. Thus, the patients current appearance falls within the spectrum of typical female appearance.  With regard to whether the requested services are considered reconstructive in nature, there is a wide spectrum of facial appearance that can be consistent with typical female appearances. In this patients case, the facial features she is seeking are consistent with a female appearance and are not considered abnormal. The requested services appear consistent with aesthetic improvement, addressing appearance concerns and are not specific to sex-related abnormalities. Thus, the requested services would be considered cosmetic enhancements and are not required to address an abnormal structure.Findings:The physician reviewer found that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prostate surgery (prostatic urethral lift implant/Urolift) for treatment of the enrollee, who has a history of acute urinary retention. Findings:  Two physician reviewers found that the enrollee has a history of significant lower urinary tract symptoms compatible with benign prostatic hyperplasia (BPH). There is also history of urinary retention requiring indwelling Foley catheterization. There is a remote history of recurrent urinary tract infections. A survey, using the American Urological Association symptoms guideline, indicated a score of 11, compatible to moderate to severe symptoms. His Uroflow parameters are suspicious for bladder outlet obstruction. Post void residual urine is 50 mL. The patient is on tamsulosin with minimal improvement in his voiding symptoms. Cystoscopy and transrectal ultrasound were compatible with BPH. The documentation indicates that this patient is unresponsive to medical therapy. Per the provider, the patient is a candidate for surgical intervention. The patient has requested authorization and coverage for prostate surgery (prostatic urethral lift implant/Urolift). The Health Plan has denied this request as investigational for the purposes of treating this patient.  Urolift procedure has been shown to be durable and effective in relieving patients with lower urinary tract symptoms related to BPH. The American Urological Association has approved this procedure as a treatment option for those patients with urinary tract symptoms related to BPH. According to a 24-month sham-controlled randomized study, the prostatic urethral lift procedure is associated with rapid symptom relief and increased urinary flow rate. Per the study, outcomes have remained stable over 24-month follow-up. The medical studies have also found that morbidity is low and sexual function is preserved. In light of recent studies indicating the clinical effectiveness of this procedure as well as the support of its use in this clinical setting by the American Urological Association, prostate surgery (prostatic urethral lift implant/Urolift) is clinically effective in this patients case. Final Result: Two reviewers determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in urology 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 enrollee has requested reimbursement for the dopamine transport scan (DatTscan) (SPECT scan) for evaluation of the enrollees essential tremor versus Parkinsons diseaseFindings:  Two physician reviewers found that while one study is not indicated for all patients with essential tremor, it has been shown to be useful in cases where the diagnosis of essential tremor and Parkinsons disease are both being considered and cannot be differentiated based on clinical grounds. There is sufficient peer-reviewed literature supporting the use of the study in differentiating cases of Parkinsons disease and essential tremor. It is imperative to provide a definitive diagnosis as treatment for essential tremor and Parkinsons disease are different and the treatments for Parkinsons disease can have significant side effects. In this clinical setting, both essential tremor and Parkinsons disease conditions were being considered and the patients diagnosis was aided by the use of the study results.  Final Result: Two reviewers determined that the diagnostic procedure at issue was 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: All three physician reviewers are board certified in neurology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Pathfinder TG system testing for evaluation of the enrollees possible pancreatic cancer. Findings:  The physician reviewers found that per the American Gastroenterological Association guidelines, the testing at issue is not listed as standard of care in the evaluation and management of cystic lesion of the pancreas. Therefore, the Pathfinder TG system testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing at issue was 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 number one, two, and three are board certified in internal medicine with sub-specialty certification in gastroenterology and 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

An enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. However, in this particular patient, there were no problems to be resolved since the patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. The two-dimensional (2D) images were reconstructed from the primary tomosynthesis acquisition, thus a routine mammogram would have been sufficient. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality. For these reasons, the use of the digital breast tomosynthesis performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the diagnostic procedure at issue was 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: the physician reviewers are board certified in diagnostic radiology 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 enrollee has requested reimbursement for computed tomography (CT) coronary angiography.Findings:  Two physician reviewers found that the preparation for ablation procedures involves imaging of the left atrium and the pulmonary veins.  This is done in order to define the anatomy of the pulmonary veins which is essential to the safety and success of the ablation procedure. There are different imaging techniques for this purpose, including CT coronary angiography, cardiac magnetic resonance imaging (MRI), or transesophageal echocardiography by ultrasound.  The use of these techniques is well accepted and considered standard for ablations.  There is sufficient support for the services at issue in this clinical setting.  Final Result: Two 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: All physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.