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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for bilateral mastectomy and nipple reconstruction. Chest surgery in transgender male minors is a common treatment for gender dysphoria. The World Professional Association for Transgender Health (WPATH) states, Chest surgery in female-to-male patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. Researchers reported that chest surgery in transgender male minors was a safe and effective treatment for gender dysphoria, noting, 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, the patient had gender dysphoria, had spent ample time living in the desired gender role, and had one year of testosterone treatment. The patients providers reported that the services at issue were medically indicated for the treatment of this patient. Therefore, bilateral mastectomy and nipple reconstruction were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the medication Ajovy. The American Headache Society (AHS) notes that treatment with monoclonal antibodies to calcitonin gene-related peptide (CGRP) may be indicated for patients with chronic migraines with an inability to tolerate topiramate. The AHS recommends that clinicians and patients reassess the benefits of CGRP monoclonal antibody therapy after three to six months and continue treatment if benefits can be documented, such as a reduction in mean monthly headache days of 50% or more relative to the pretreatment baseline. The U.S. Food and Drug Administration (FDA) has approved the use of Ajovy, a CGRP antagonist, for the preventive treatment of migraines in adults. In this case, the patient has a history of chronic migraines that did not respond to topiramate and metoprolol. Given that the patient fits AHS criteria for treatment with CGRP monoclonal antibody therapy, the requested medication is medically indicated. Therefore, Ajovy is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the last four days of an inpatient hospital stay.Findings:  The physician reviewer found that the submitted records do not support that the services at issue were medically necessary. In this case, the patient had a complicated post-operative course following her cesarean delivery and required a prolonged inpatient stay after delivery. However, by the last four days of the patients inpatient hospital stay, the submitted documentation reflects that the patient had a treatment plan of continued oral antibiotics and observation only. The patient had continued to progress towards recovery, she was tolerating her oral antibiotic regimen, and her white blood cell count was continuing to trend down. The patient did not have any evidence of continued hemodynamic instability or distress. She had been managed on oral antibiotics for multiple days with no change in plan to complete the course. Her bloodwork showed bandemia but was trending in the appropriate direction. The only reason cited for a continued inpatient stay was `inpatient management per primary provider.` Provider preference with no supporting clinical documentation is not an indication for continued inpatient stay. Records reflect that the patient could have been safely and effectively cared for during the last four days of her inpatient hospital stay in an outpatient setting. Under these circumstances, the dates of inpatient hospital stay at issue were not medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary to treat 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:The parent of a one-year-old male enrollee has requested authorization and coverage for an OtoSCOPE hearing loss genetic testing panel. The International Pediatric Otolaryngology Group (IPOG) consensus recommendations for the workup of hearing loss in pediatric patients reported that in the setting of SNHL, comprehensive genetic testing is an appropriate next step following physical examination and audiogram. Researchers found in a study of 1,119 patients that comprehensive clinical genetic testing with targeted genomic enrichment and massively parallel sequencing identified an underlying genetic cause for hearing loss in 39% of patients. Researchers identified an overall diagnostic rate of 41% with hearing loss genetic panels using massively parallel sequencing. The medical literature noted that comprehensive genetic testing should form the cornerstone of a tiered approach to the clinical evaluation of patients with hearing loss. The OtoSCOPE panel includes testing for markers of Pendred syndrome. In this case, based on available clinical documentation and peer-reviewed evidence, an OtoSCOPE genetic testing panel is likely to be more beneficial in identifying the underlying etiology of the patients congenital SNHL, as compared to other available standard interventions. Therefore, an OtoSCOPE hearing loss genetic testing panel is likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested service is 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 service 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: Physician reviewers 1, 2, and 3 are board certified in otolaryngology 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 patient is requesting reimbursement for Euflexxa injections. Findings: 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 patients options are limited. The patient has tried and failed other conservative treatments, including oral nonsteroidal anti-inflammatory drugs (NSAIDs), topical diclofenac, physical therapy, and a corticosteroid injection, with the alternative being a total knee arthroplasty. The medical evidence supports the services at issue in this clinical setting. Therefore, the Euflexxa injections received were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Guardant360 genetic testing provided by Guardant Health. Molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered with the current standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) guidelines strongly recommend broad molecular profiling with the goal of identifying rare driver mutations for which effective therapies may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Integration of plasma next generation sequencing into the routine management of stage IV NSCLC demonstrates a marked increase of the detection of therapeutically targetable mutations and improved delivery of molecularly guided therapy. Given this support, the Guardant360 genetic testing provided by Guardant Health was 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 genetic testing provided by Guardant Health was 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 certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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 FoundationOne CDx comprehensive genomic profiling test. This patient has triple negative breast cancer that was advanced in presentation and is now metastatic. The records indicate that she is treatment-naive and can expect a response from chemotherapy. The patient reportedly refused treatment with chemotherapy. Decisions regarding chemotherapy should consider patient preference, goals of treatment, the presence of toxicities from previous therapies, and the availability of alternative treatment options. In order to provide these options to this patient, the provider recommended mutational testing with FoundationOne CDx. One study evaluated 86 patients and found that the progression-free survival (PFS) on regimens selected by molecular profiling yielded a 27% survival advantage when compared to PFS on the most recent chemotherapy regimen. Additional data on breast cancer also supports the utility of FoundationOne testing in this patients clinical setting. All told, the FoundationOne CDx comprehensive genomic profiling test was 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 FoundationOne CDx comprehensive genomic profiling test was 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 certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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 patient has requested authorization and coverage for proton beam radiation therapy. Given this patients unique clinical circumstances, proton beam radiation therapy is considered the standard of care. Given the patients young age and presence of Li-Fraumeni syndrome, she is at a heightened risk for radiation-induced toxicity, including secondary malignancy. Li-Fraumeni syndrome is known to result in increased normal tissue radiosensitivity per high quality clinical outcomes published in the peer-reviewed medical literature. It is critical to minimize the exposure to the patients right lung, heart, and uninvolved soft tissues. The provider has supplied a photon versus proton plan comparison, which demonstrates a clinically significant reduction in normal tissue exposure with the proton radiotherapy plan. Based on the treatment plan, proton radiation therapy is expected to minimize the incidence of acute and late radiation-induced morbidity compared with photon-based radiotherapy. Given the presence of Li-Fraumeni syndrome, the patients young age, and the fact that the patient is being treated with curative intent with long life expectancy, proton radiation therapy is consistent with the American Society for Radiation Oncology (ASTRO) guidelines. Thus, the requested proton beam radiation therapy 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 radiation oncology 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 of MRI of the left shoulder. Findings:  The physician reviewer found that correlative magnetic resonance images may be used in diagnosing the presence of three common shoulder pathologies, including rotator cuff pathology. In this case, the patient reported posterior shoulder pain, limitation of motion, and pain while sleeping. The provider suspected a rotator cuff tear and recommended an MRI scan and an orthopedic consultation. As the MRI may provide information that may aid in treating and managing the patients pain, the requested service is medically indicated. Therefore, MRI of the left shoulder 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 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 Synvisc-One injections in both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and 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, the patient has a history of bilateral osteoarthritis and several years of documented benefit from prior Synvisc-One injections. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Synvisc-One injections in both knees are 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 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

The patient has requested authorization and coverage for internal medicine with subspecialty certifications in medical oncology and hematology. Hereditary hemorrhagic telangiectasia (HHT) is a genetic disease that causes multiple arteriovenous malformations in various organs. Common presentations include epistaxis, mucocutaneous arteriovenous malformations, and gastrointestinal bleeding. High output heart failure is significantly advanced disease that requires immediate intervention. These arteriovenous malformations are not amenable to ablation but have been shown to respond to treatment with bevacizumab (Dupuis-Girod, et al.). This patients records document that she has failed treatment with bevacizumab. Her provider has recommended treatment with Votrient. Faughnan and colleagues reported that Votrient is a tyrosine kinase inhibitor that blocks VEGF [vascular endothelial growth factor] receptors potentially serving as anti-angiogenic treatment for HHT. The authors found that patients showed a decrease in epistaxis and some showed sustained improvement. Given this support, the requested Votrient (pazopanib) 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 oral enteric-coated budesonide. Findings:  The physician reviewer found that the American Association for the Study of Liver Diseases (AASLD) included budesonide in recommendations for first-line treatment of autoimmune hepatitis. The guidelines cited a 90% first-pass hepatic metabolism of budesonide, resulting in a lower risk of systemic side effects. Zandieh and colleagues found that budesonide had successfully been used to treat patients with autoimmune hepatitis who were intolerant to prednisone and azathioprine. Gleeson noted that budesonide was recommended in non-cirrhotic patients who developed prednisolone-related side effects. In this case, the patient had type 1 diabetes and reported elevated blood sugar as a side effect of prednisone. She was documented as stable, using budesonide to treat her autoimmune hepatitis. Therefore, oral enteric-coated budesonide is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.