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

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested coverage for inpatient psychiatric services from 2/15/19  2/19/19. The Health Plan denied this request as not medically necessary. A review of the records indicates the enrollee with a history of Bipolar Disorder, Alcohol Use Disorder, Depression, and Body Dysmorphia Disorder presented to the hospital with reports of worsening depressive symptoms, suicidal ideation, and seven days of alcohol use.  He had reports of a past suicide attempt.  He was drinking many shots of alcohol per day for the week prior to admission.  He had reports of impaired functioning including missing work. Medications included Fluoxetine and Olanzapine.  He lived with his family. He was admitted to the inpatient mental health level of care and received medication management, group and individual therapy, and was followed by Psychiatry, Social Work and Occupational Therapy. Review of the records indicates this was a high risk patient due to his initial clinical presentation of having worsened depression with suicidal plans to overdose or cut his wrists and past reported suicide attempt.  According to the medical literature, patients with past suicide attempts are at high risk for suicide and past suicide attempts are the most reliable predictors of suicide. These patients may require more time in the hospital to better assess risk of suicide because sometimes they do not tell the truth regarding suicidal thoughts in order to leave the hospital. This enrollee was considered a high risk patient and was a candidate for inpatient acute hospital treatment as he had continued depression, had two suicidal plans on admission and a past reported suicide attempt. Notes after admission reported that his depression was still significant and was rated an 8 out of 10. He was isolative, guarded, withdrawn, and depressed. He was not interacting with peers and was still depressed. In addition to the suicidal plans, he was drinking heavily so he was also at risk for life threatening withdrawal.  The inpatient level of care was appropriate for one day.  However, as of the third day notes indicate that he denied suicidal ideation, had improved mood and was compliant with medications. A note the next day reported that he felt better and his depression was less at 3 out of 10 and he still denied suicidal ideation.  He was discharged one day later. Thus, the inpatient level of care was not appropriate for the subsequent two days.Final Result: The reviewer determined that the requested service was medically necessary for one of the days, but not medically necessary for the subsequent days for treatment of the enrollees medical condition. Therefore, the health plans denial should be partially overturned. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for SPECT scan for cognitive changes. The medical records indicate the enrollee was diagnosed with migraine without aura and major depressive disorder.  A clinical note indicated that the enrollee was seen in the office for a neurological evaluation.  A CT of the brain was showing moderate frontal lobe atrophy.  The enrollee indicated she had a herniated nucleus pulposus at the L3-4 with some cognitive changes at work and numbness and tingling of the extremities.  The enrollee had an MRI of the brain that showed mild to moderate frontal lobe atrophy.  She had neuropsychiatric testing that showed there were no deficits at all.  The repeat neuropsychiatric testing was also normal.  Upon review of the MRI, the enrollee did have some degree of atrophy of the frontal and anterior temporal lobes.  The possibility of frontotemporal neurodegenerative issues were discussed with the enrollee.  They indicated there was a need for repeat neuropsychiatric testing, as well as a SPECT scan.  There is no consensus statement that indicates SPECT is useful for the diagnosis of frontotemporal dementia. Also, when compared with PET, SPECT has a lower  diagnostic  accuracy and is inferior in its ability to separate healthy controls from patients with true dementia. SPECT has not been shown to have definite diagnostic benefit. The documentation indicates that the enrollee previously had an MRI that did show some degree of atrophy to the frontal and anterior temporal lobes and previously underwent neuropsychiatric testing that was normal.  There was no clear rationale for additional imaging studies as the enrollees condition was noted to be stable with no current signs or symptoms.  Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Neurology 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: The patient has requested authorization and coverage for subcutaneous implantable cardioverter defibrillator (ICD). Based on the records provided for review, the patient has hypertrophic cardiomyopathy. The patients records document an increased risk of sudden death as evidenced by sudden death in his brother and non-sustained ventricular tachycardia (NSVT). In this circumstance, placement of a cardioverter defibrillator is appropriate. However, there is no documented contraindication to a standard implantable cardioverter defibrillator using a transvenous ventricular lead. In addition, optimal patient selection criteria and long-term complications with a subcutaneous leadless defibrillator have not been established. Further, a subcutaneous leadless defibrillator does not have the capability of providing back up cardiac pacing in cases of bradycardia or anti-tachycardia pacing as a first tier approach for treating spontaneous ventricular tachycardia. By contrast, a standard transvenous defibrillator has these capabilities. All told, the requested subcutaneous implantable cardioverter defibrillator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three of the three 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:  One reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acetaminophen with codeine (Tylenol with codeine) liquid. The U.S. Food and Drug Administration (FDA) has issued its strongest warning against the use of codeine medications for use in children under 12 years of age. Specifically, the FDA states that codeine carries serious risks, including slowed or difficult breathingwhich appear to be a greater risk in children younger than 12 years. In this case, the patient is currently seven-years-old and has been diagnosed with a hyperextension injury to his right knee. The imaging of the joint did not reveal a fracture or dislocation. The provider recommended conservative management with ice, compression with ACE bandage, and elevation of the leg for knee pain. The patient was prescribed ibuprofen and Tylenol for pain control. The providers dated 4/29/19 state the patient has not exhausted the recommended therapeutic regimen of ice, compression, elevation, and ibuprofen and Tylenol. All told, the requested acetaminophen with codeine (Tylenol with codeine) liquid is not medically necessary for the treatment of knee pain.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 anesthesiology with subspecialty certification in pain management 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 Lyrica 50 mg capsules, one capsule three times a day.  Findings:  The physician reviewer found that the patients pain can be described as a form of post-traumatic neuropathic pain. Physical examination confirms decreased sensation of the foot and loss of discrimination of sharp and dull touch. The patient has failed to respond to two different classes of neuropathic pain medications at therapeutic doses. Specifically, the patient was treated with gabapentin 300 mg three times a day, and Cymbalta 60 mg. The provider recommended to switch the patient to Lyrica in an attempt to provide better neuropathic pain control. Addressing the issue of current treatment options for neuropathic pain, the National Institute for Health and Care Excellence (NICE) guidelines recommend offering a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain. The NICE guidelines further state that if the initial treatment is not effective or is not tolerated, offer one of the remaining three drugs, and consider switching again if the second and third drugs tried are also not effective or not tolerated. In addition, Derry and colleagues found ample data in the peer-reviewed medical literature demonstrating that Lyrica is safe and effective for treatment of patients with post-traumatic neuropathic pain. Based on the current evidence and treatment guidelines in the medical literature, the request for Lyrica 50 mg capsules, one capsule three times a day, to treat the patients post-traumatic neuropathic pain is supported as medically necessary.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 anesthesiology with subspecialty certification in pain management 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

The patient has requested authorization and coverage for right-sided minimally invasive sacroiliac (SI) joint fusion with triangular implants (iFuse procedure). SI joint degeneration is a common cause of chronic low back pain. Minimally invasive fusion procedures have demonstrated successful relief for patients with chronic low back pain who have failed conservative treatment. Among these implants, the triangular titanium implants such as iFuse, have been established in the medical literature to be safe and effective. Recent studies have documented two-year follow-up of these procedures can result in meaningful clinical improvement, maintained pain relief, and evidence of a solid fusion on imaging studies. Colleagues reported on long-term results from a prospective multicenter clinical trial. In this study, patients with SI joint dysfunction underwent minimally invasive SI joint fusion using triangular titanium implants. The authors found that treated patients showed marked improvements in pain, disability, and quality of life at two years. This patients records document the presence of chronic low back pain that has not responded to standard conservative measures. The patient has no evidence of neural compression on MRI, yet there are clinical findings of SI pain, which is relieved by injecting the SI joint. Given these findings, the requested right-sided minimally invasive SI joint fusion with triangular implants (iFuse procedure) is likely to be of greater benefit for the medical condition of this individual than any other standard treatment.Final Result: Two of the three reviewers determined that the requested services are 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for facial feminization procedures (punch graft hair transplant > 15 punch grafts (15776); suction assisted lipectomy head and neck (15876); genioplasty 2/ sliding osteotomies (21122); repair, revision, and/or reconstruction of mandibular rami and/or body, sagittal split, without internal rigid fixation (21195); osteoplasty facial bones reduction (21209); malar augmentation prosthetic material (21270); rhinoplasty primary complete external parts (30410); repair brow ptosis (67900)). The World Professional Association for Transgender Health (WPATH) acknowledges that for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. WPATH further states that in a patient with severe gender dysphoria, facial feminization procedures can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. Moreover, facial feminization surgery can improve quality of life in transgender women. Based on the available documentation, the rationale for the requested surgery is to alleviate the patients clinically significant distress related to gender dysphoria. Specifically, the records establish that the purpose of the surgery is to directly treat the patients gender dysphoria. Further, the photographs show the patient has male features that can be addressed by the requested procedures. Thus, the requested facial feminization procedures (punch graft hair transplant > 15 punch grafts (15776); suction assisted lipectomy head and neck (15876); genioplasty 2/ sliding osteotomies (21122); repair, revision, and/or reconstruction of mandibular rami and/or body, sagittal split, without internal rigid fixation (21195); osteoplasty facial bones reduction (21209); malar augmentation prosthetic material (21270); rhinoplasty primary complete external parts (30410); repair brow ptosis (67900)) are medically necessary for this patient. Final Result: The reviewer determined that the requested surgery 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Rezum water vapor therapy. This patient presents with moderate bladder outlet obstructive complaints. The patient has a symptom score of 15 with complaints of nocturia and urgency. The records document that he was placed on behavioral modification with decreased caffeine intake and was treated with tamsulosin with some improvement in his symptoms. He was also noted to have an elevated prostate specific antigen (PSA) of 8.0. The patient underwent transrectal ultrasonic guided biopsy of prostate which revealed an approximately 36-gram prostate. The provider recommended treatment with Rezum water vapor therapy. In the current peer-reviewed medical literature, found that Rezum provides early effective and durable relief of benign prostatic hyperplasia symptoms with preservation of sexual function in subjects followed up for three years and is applicable to treatment of the median lobe and hyperplastic central zone tissue. As this patients condition has not substantially improved with behavior modification and tamsulosin, the requested Rezum water vapor therapy is 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 requested services are 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:  One reviewer is board certified in urology and is actively practicing. One Reviewer is board certified in urology and is actively practicing.  One Reviewer is board certified in urology 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:  The enrollee requested coverage for advanced lipoprotein testing. The enrollee has been diagnosed with dyslipidemia and vitamin D deficiency.  He underwent advanced lipoprotein testing. The medical literature indicates that generally patient care issues related to screening, diagnosis, and treatment are based on the results of the measurement of serum lipids, which is generally accomplished by obtaining a lipid profile.  On occasion, measurement of serum lipoproteins is necessary for one or more of these purposes. There are strong associations between total LDL particle concentration and cardiovascular disease, which provide a rationale for advanced lipoprotein testing for total LDL particle numbers in cardiovascular risk assessment and treatment. The lipid profile and its components (total cholesterol, low density lipoprotein cholesterol, high density cholesterol, and triglycerides) are some of the most commonly ordered laboratory tests in clinical practice.  The most common indication for this test (or its components) is for aiding the process of determining cardiovascular disease event risk.  The enrollee underwent extensive laboratory testing and had a diagnosis of dyslipidemia.  The records that were provided indicated that the enrollee was to undergo advanced testing to determine cardiovascular risk.  The rationale for advanced testing with the particles included was not noted.  The literature indicates that the most commonly ordered tests are total cholesterol, low density lipoprotein cholesterol, high density cholesterol, and triglycerides. A search of the guidelines failed to indicate there was a recommendation of testing for advanced lipoproteins to establish heart disease risk.  The literature indicates therapies targeting HDL and HDL composition have been disappointing to date. It remains to be determined whether these tests incrementally add to cardiovascular risk predicted by traditional risk factors.  More importantly, it has yet to be determined whether treatment strategies guided by, or targeting, these measures improve cardiovascular outcomes. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Cardiovascular Disease 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.