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

An enrollee has requested authorization and coverage for facial feminization surgery and a tracheal shave.The patient has submitted multiple documents that support her claim that the requested surgeries are a medical necessity. A letter from the patients therapist states that the requested facial feminization surgeries and tracheal shave will serve to decrease the patients felt emotional effects of gender dysphoria. The patients primary care provider also supports the medical necessity of the requested surgeries to treat the patients gender dysphoria. Under these circumstances, the requested facial feminization surgeries and a tracheal shave are medically necessary to treat the patients gender dysphoria.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: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for a right leg prosthesis with a microprocessor. The submitted documentation does not reveal that the patient would be unable to perform his activities of daily living with an appropriately fitted non microprocessor standard knee prosthesis. Furthermore, there is no objective evaluation of the patient's back or spine from a physician or imaging study of the spine that provides objective evidence that the patient has a documented comorbidity of the spine that would require an endoskeletal knee shin system. There is also no objective evidence that indicates that the patient has abnormal right hip extension and/or quadriceps function that impairs K3 level functioning with the use of a microprocessor-controlled knee alone rather than the requested endoskeletal knee shin system with microprocessor control. In addition, the submitted documentation does not demonstrate that the patient has a regular need for long distance ambulation at variable rates, a need for regular ambulation on uneven terrain, or a need for regular use on stairs that cannot be met with an appropriately fitted standard prosthesis. Furthermore, there is no evidence of a plan and a particular job that the patient is returning to that requires the requested prosthesis for employment over a standard prosthetic device. Under these circumstances, the requested right leg prosthesis with a microprocessor is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medical device 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 physical medicine and rehabilitation, with subspecialty certification in neuromuscular medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for the medication, Dutasteride 0.5 mg. The enrollee has androgenetic alopecia. His symptoms include hair loss and inflammation with itchiness and pain. He has tried Rogaine, but he reports it made his scalp worse. He has also tried Nizoral, which helped the inflammation, but not the hair loss. He started Dutasteride, 0.5 milligram daily, Finasteride 1 milligram daily, and the topical steroid cream, Fluocinonide, daily. The enrollee was evaluated for a refill of Dutasteride. The enrollee reported he experiences hair loss and a red and painful scalp without the Dutasteride. The provider recommended finasteride, but the enrollees preference was for Dutasteride. Literature shows dutasteride may be superior to finasteride in improving hair growth in young males. However, adverse sexual side effects are more common with dutasteride than with finasteride. Researchers report the therapeutic options with the highest level of evidence remain finasteride and minoxidil for male androgenetic alopecia. This enrollees symptoms include inflammation with itchiness and pain. The use of Dutasteride will decrease dihydrotestosterone levels but it is not an anti-inflammatory; and thus will not treat, nor is it approved for treating, this enrollees inflammation-related symptoms.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for medication Emtricitabine-Tenofovir Alafenamide (Descovy). The enrollee has a medical history of diabetes mellitus and high cholesterol. The enrollee indicates he would like to take advantage of an alternative from his current medication with a better safety profile, especially in maintaining healthier kidney functions. A governmental body approved Descovy for use as a pre-exposure prophylactic medication for the prevention of human immunodeficiency virus infection. A study showed both agents were effective in reducing the likelihood of human immunodeficiency virus infection. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollee requested authorization and coverage for balloon sinuplasty. The enrollee has chronic sinusitis. She reports three to four sinus infections per year that do not completely resolve; despite treatment with antibiotics. She underwent surgery, but the procedure did not improve her symptoms of sinus pressure, aural fullness, nasal congestion, and post nasal drip. A computed tomography of the sinuses showed moderate to severe pansinus disease. Balloon is the endoscopic use of a balloon device to enlarge or open the outflow tracts of sinuses; as a stand-alone procedure or with endoscopic surgery.  However, because endoscopic sinus surgery does not directly treat the underlying inflammatory disorder, sinus surgery must be followed by medical management to control the inflammatory processes or symptoms will invariably return. The medical records are insufficient to show medical management has not been successful for this enrollee. The records indicate the enrollee has had a positive allergy test that included multiple allergens, but the records did not show evidence her allergies had been treated.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 otolaryngology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting reimbursement for Orthovisc injections for the right knee. The enrollee has pain in the right knee. He has a chondral defect of the lateral femoral condyle in the right knee. He continued to experience pain, swelling, stiffness, popping, catching, instability, and weakness. The orthopedic surgeon advised treatment with viscosupplementation and ordered Orthovisc injections for the enrollee, along with continued use of his custom knee brace. According to a professional society, the use of intra-articular hyaluronic acid injections is indicated for the treatment of osteoarthritis in the knee in adults who do not respond to other treatment options. Records show the enrollee demonstrated symptom improvement with previous hyaluronic acid injections. The magnetic resonance imaging scan shows arthritic change and degeneration of the joint. Based on the positive response to hyaluronic acid injections and the literature support for hyaluronic acid injections for osteoarthritis, literature supports the hyaluronic acid injection to the knee is clinically appropriate and medically necessary to treat this enrollee's medical condition.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Euflexxa injections to both knees. The patient has been diagnosed with osteoarthritis of both knees. The provider noted that the patient reported good results with previous Euflexxa injections and requested repeat injections. 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. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient has a history of benefit from prior viscosupplementation injections. Furthermore, the patients options are limited, with the alternative being total knee arthroplasties. The medical evidence supports the requested services in this clinical setting. 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: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for Nerlynx 40mg tablets, as adjuvant treatment with trastuzumab therapy. The enrollee has stage IV breast cancer. The peer-reviewed medical literature reports Nerlynx has been used after trastuzumab; but not with trastuzumab. The safety and efficacy of the combination of these two therapies together is unknown. Researchers report adjuvant pertuzumab and neratinib (Nerlynx) modestly improves disease-free survival in early breast cancer, especially for those with a high risk of recurrence. A lack of complete response to preoperative chemotherapy and human epidermal growth factor receptor-2 targeted therapies is associated with worse outcomes. Future trials must focus on de-escalation of chemotherapy and biomarkers for further tailored therapy in early human epidermal growth factor receptor-2 positive breast cancer.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for dehydroepiandrosterone (DHEA). The enrollee was diagnosed Sjogrens syndrome. The enrollee reports weakness and episodes of an inability to move his body or limbs for timespans of two to four hours. He also has pinkness of the face and redness over the knuckles of his fingers. Medical records show the enrollee has undergone multiple tests, but has not received a definitive diagnosis for his leg weakness. Repeat laboratory testing showed the enrollee was negative for Sjogrens syndrome. Because of the test results, the physician was not willing to prescribe an immunosuppressive medication. Professional society criteria standardize the definition of lupus for study purposes. It is possible to meet the criteria and not have systemic lupus erythematosus, or not meet the criteria yet still have the disease. It is unusual to have active systemic lupus erythematosus with a negative result for anti-nuclear antibody, as is the case with this enrollee. This enrollee is currently serologically negative without overt signs of systemic lupus erythematosus. The benefit of dehydroepiandrosterone (DHEA) is not established. It has potentially feminizing side effects in men. There are also concerns about high blood pressure and an increased risk of heart disease, and an increased risk of prostate or other cancers.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in internal medicine and rheumatology 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: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for a power scooter. The enrollee has chronic low back pain with lumbar radiculopathy, osteoarthritis of the hips, and high body mass index. The physician reported the enrollees pain seemed to be affecting her ability to walk and stand for long durations, and a power scooter was reasonable. The occupational therapist notes the enrollee does not require a mobility device inside the home, but the enrollee stated she needed it for stores that do not provide mobility devices and for vacation. The enrollee reports she can only walk very short distances. Literature shows significant health and safety issues with the use of motorized mobility scooters, including the potential for deconditioning with the exacerbation of underlying chronic conditions, and the potential for operator and pedestrian injuries due to unintended collisions. Studies also demonstrated long-term use of these devices resulted in detrimental effects on cardiovascular performance and insulin resistance, with a resultant increased risk of diabetes prevalence. The requested power scooter is not considered medically necessary for the members medical condition and intended utility. Her home is not power scooter accessible, nor does she intend to use the power scooter at home. Use within the community is considered a convenience, and not for medical needs. Furthermore, the medical records do not support why a manual wheelchair is contraindicated.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for reimbursement for toenail and callus trimming. The enrollee has diabetes mellitus, and was evaluated by a podiatrist for dermatophytosis of the toenails. Records showed the enrollee had a fungal infection of the toenails and an ulcer on the second toe of his left foot, which was debrided during the visit. He returned twice for the same complaints and underwent sharp debridement of 10 nails and four calluses on both visits. The enrollee reports he cannot feel his feet; therefore, he cannot determine how much nail or callus to remove before he cuts into his flesh and causes a wound. The enrollees diabetes causes foot wounds that do not heal normally, resulting in a risk of gangrene and possible amputation. Literature reports preventative strategies for diabetics include annual diabetic foot screening and diabetic foot care interventions. This allows for early identification of those who are at high risk for diabetic foot complications. Literature reports treatment for diabetic foot ulcers should start when a possible pre-ulcer is discovered. This can reduce the development of more severe diabetic foot ulcers. Once a diabetic foot ulcer has developed, care should be optimized for both the enrollee and the wound bed. Routine foot inspection and preventative care is critical for diabetics with neuropathy.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in podiatric 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollees parent is requesting reimbursement for neuropsychological testing. The enrollee has persistent depressive disorder. She underwent psychotherapy and received a psychoeducational assessment for academic challenges, including difficulty with reading, letter and number recognition, and retrieval. The enrollees mother reported the enrollee had challenges with mood regulation, social navigation skills, attention and concentration skills, and planning and organization skills. Neuropsychological testing resulted in recommendations for medication consultation, cognitive-behavioral therapy, dialectical behavior therapy, social skills training, behavioral programs for sleep disruption and exercise, speech-language therapy, and educational remediation. The neuropsychological assessment also resulted in diagnoses of dysthymic disorder, intermittent major depressive episodes, social pragmatic communication disorder, and attention deficit hyperactivity disorder. Depending upon the age of the child, the childs level of tolerance and the numbers of tests, the assessment itself may require multiple days. In addition to conducting tests, a parent and child interview and feedback session is performed.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for voice feminization therapies. The enrollee has gender dysphoria of adulthood. She has been living full-time as a woman and began hormone therapy. However, records indicate her gender dysphoria has persisted due to the low pitch of her voice, resulting in anxiety, depression, and agoraphobia. The enrollees transgender health consultant reports the enrollees gender is frequently misidentified due to her low voice, and this exacerbates the enrollees symptoms of gender dysphoria. The consultant indicates transgender women face the highest rates of suicidality and the enrollees pitch of her voice leaves her vulnerable to transphobic violence. Literature shows voice is highly related to gender. Literature notes the treatment goal for transgender people who present with voice and communication complaints is to help them achieve a gender congruent voice in an efficient and safe manner. Treatment can be accomplished through behavioral and medical or surgical intervention. Literature describes the importance of a gender congruent voice on psychosocial well-being and quality of life.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The Psy.D reviewer is board certified in psychology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for requested Euflexxa injections in both knees. The enrollee has bilateral knee osteoarthritis, left worse than right. Prior treatment with hyaluronic acid lasted about five to six months, with good improvement in her pain. The enrollee reported her pain had recurred over the past couple of months. She described it as aching and dull. She also noted minimal intermittent knee swelling. Given her lack of improvement with treatment modalities to date, the enrollee received a trial of viscosupplementation, with Orthovisc Injection #1 provided during the office visit. Intra-articular hyaluronic acid injections (Euflexxa) are standard practice for the treatment of mild-to-moderate knee arthritis. This enrollees history and response indicate she is a good candidate for the requested intra-articular hyaluronic acid injections (Euflexxa).Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.