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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for vocal feminization surgery (Wendler glottoplasty) and post-surgical speech therapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. Findings: Voice and communication treatment result in gains important to listeners perception of gender. Laryngeal surgery has an important role in raising the fundamental frequency in those who have not achieved acceptable voice via non-surgical means. Surgical procedures include laryngoplasty with or without thyrohyoid approximation, Wendler glottoplasty, cricothyroid approximation, laser glottoplasty reduction and the vocal fold shortening and retrodisplacement of anterior commissure.  Vocal cord shortening procedures can result in the largest increase in fundamental frequency. In addition, post-speech therapy is indicated as part of this patients voice treatment. Therefore, vocal feminization surgery (Wendler glottoplasty) and post-surgical speech therapy are medically necessary for treatment of this patients medical condition.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 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services provided on the basis that the services were emergent in nature. The Health Plan has denied this request indicating the enrollee was not experiencing an emergency medical condition. This patient sustained a right patellar fracture following a slip and fall onto her right knee. She was examined by an in-network orthopedic surgeon who diagnosed a right knee patellar fracture. She was placed in a long-leg cast and open reduction and internal fixation surgery was scheduled. She sought a second opinion with an orthopedic specialist who confirmed a displaced transverse patellar fracture of the right knee and recommended open reduction and internal fixation surgery. She subsequently underwent open reduction and internal fixation of the right patella with the out-of-network surgeon. The patient states that this was an emergency situation as she had been bedridden and did not have time to see a third in-network orthopedic surgeon and wait for surgery again. Based on the records, the services provided to this patient did not meet the definition of emergency medical services. The submitted records do not demonstrate that the patient was experiencing acute symptoms of sufficient severity that a delay in surgery would cause a serious deterioration in her condition. The services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld.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: A 56-year-old female enrollee has requested authorization and coverage for Mavyret. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. These recommendations apply regardless of fibrosis stage. The guidelines cite data showing reduced survival with delayed treatment  For these reasons, the requested treatment with Mavyret is supported as medically necessary for the treatment of this patients hepatitis C infection.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. Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement for the Propel sinus implant. Propel sinus implants are now considered an adjunct to the healing properties after routine endoscopic sinus surgery and many reports attest to the benefit of the healing and absence of scar formation. However, there is a lack of long-term clinical trials to demonstrate the benefit of the Propel sinus implant. A study reported that there were unable to provide evidence to establish whether steroid-eluting sinus stents have potential advantages and disadvantages for patients with chronic rhinosinusitis undergoing functional endoscopic sinus surgery. Future, high-quality randomized controlled trials are needed to assess whether or not steroid-eluting sinus stents confer any beneficial effects, over those of surgery alone, when compared to non-steroid sinus stents. Given these findings, the Propel sinus implant was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the Propel sinus implant was 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 services at issue were 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 otolaryngology and is actively practicing. One Reviewer is board certified in otolaryngology and is actively practicing.  One Reviewer is board certified in otolaryngology 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

Nature of Statutory Criteria/Case Summary: The parent of a seven-year-old male enrollee has requested authorization and coverage for speech therapy. Although the Oral and Written Language Scales, Second Edition (OWLS-2) addresses pragmatic language skills, the majority of the test focuses on listening skills and expression. The study demonstrated that none of the available pragmatic tests are fully reliable for assessing a patients skills in inferencing, which is a pragmatic skill. Therefore, evidence of improvement on standardized testing for a child with autism is challenging. Group speech therapy is indicated because this patient has autism spectrum disorder and pragmatic language skills score of 5% on the OWLS-2. Further monitoring of the patients progress toward pragmatic language goals should help identify whether group therapy is effective. This patients records indicate that his parent reported that speech therapy 20 minutes from their home was difficult to manage. If the parent cannot transport the patient to therapy, this may explain the patients lack of progress. Participation is essential to the patients ability to achieve goals in therapy. Given the support in the medical literature, the requested speech therapy is medically necessary for treatment of this patients medical condition.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 pediatrics with expertise in developmental behavioral 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for E0694 ultraviolet multidirectional light therapy for home use. There is sufficient support for the requested device in this patients case. She has tried and failed therapy with topical steroids and topical immunomodulators. Atopic dermatitis is known to be a chronic condition. Phototherapy has been shown to be useful in the treatment of atopic dermatitis. Per the records, she has shown improvement with in-office treatments.  The medical evidence supports the requested device in this clinical setting. Therefore, E0694 ultraviolet multidirectional light therapy for home use is medically necessary for the treatment of this patient. 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 reviewer is board certified 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 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 LINX Reflux Management System. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees gastroesophageal reflux disease.Findings There is a lack of randomized controlled trials with long term follow up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. One best evidence review concluded that long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Additionally, LINX (to a greater extent than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. Another evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. There are 29 reports of LINX erosion through the esophagus in the publicly accessible U.S. Food and Drug Administration Adverse Events database, among other adverse events. The currently available peer reviewed literature does not definitively support the conclusion that LINX is likely to be more beneficial than standard treatment in this clinical setting. For these reasons, LINX Reflux Management System is not likely to be of greater benefit for the treatment of this patients GERD symptoms than any available standard therapy.Final Result: Two of the three reviewers determined 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a consultation with a neuro-ophthalmologist. The records provided for review document that this patient developed consecutive exotropia after bilateral medial rectus muscle recessions for congenital esotropia. This is not uncommon and the provider noted that multiple surgeries may be required for management. However, the patients clinical presentation does not support an evaluation with a neuro-ophthalmologist. This patient has a condition that is commonly treated by pediatric ophthalmologists. Thus, the requested consultation with a neuro-ophthalmologist is not supported as medically necessary for further evaluation and treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in ophthalmology 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: A transgender female enrollee has requested authorization and coverage for consultation regarding voice modification surgery and speech therapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. Findings: There is support in the medical literature for the medical necessity of the requested services in this clinical setting. This patient is requesting consultation regarding voice modification surgery and speech therapy. Voice and communication treatment by nonsurgical and surgical methods results in gains important to listeners perception of gender. People transitioning from male to female gender seek speech language pathology services when they feel their voice is betraying their genuine self or perhaps is the last obstacle to representing their authentic gender. Speaking fundamental frequency (pitch) and resonance are most often targets in treatment because the combination of these two voice characteristics can account for the majority of how listeners perceive a speakers gender. However, current studies indicate that pitch is not the sole contributor to perceptions of gender. Intonation, voice quality, pragmatics and nonverbal communication contribute to a lesser extent but are usually recommended in treatment guidelines. Modification of vocal resonance has been shown to increase perceptions of a speaker as female. There is evidence that encouraging precise articulation results in increased perceptions of the speaker as female. Voice and communication treatment results in gains in areas important to listeners perception of gender. A review of the literature suggests that speech and language therapy are successful at creating an acceptable fundamental frequency in transgender patients, as well as influencing other communication behaviors. Additionally, outcome measures have indicated that speech therapy is effective in increasing vocal pitch and perceptual femininity without compromising vocal quality. As such, in this patients case, consultation with a speech therapist can be an effective method for treating her symptoms related to gender dysphoria. In sum, the requested consultation regarding voice modification surgery and speech therapy have been established as medically necessary for treatment of this patients medical condition.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 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 Forfivo XL 450 mg. Bupropion is a dual-acting medication that enhances both noradrenergic and dopaminergic tone in the central nervous system. The medication was approved by the U.S. Food and Drug Administration (FDA) for treatment of depression in 1989 and has established itself as a reliable and well-tolerated anti-depressant. A twice per day sustained acting preparation was released in 1996, followed by the once-daily extended-release (XL) formulation in 2003, and then the Forfivo preparation in 2012. Forfivo provides a unique benefit to patients as it allows for the maximum daily dosage of 450 mg to be delivered in a single tablet, rather than a multi-dose combination, which optimizes treatment adherence without increasing the risk for side effects. Thus, Forfivo is a reasonable treatment intervention for patients with major depressive disorder. In this case, the provider noted that the patient requires this long acting medication. Further, the documentation supports that the patient failed standard alternatives and has been doing well on this formulation of the medication. The intervention is consistent with good medical practice and reasonably expected to improve his depression and prevent an exacerbation of illness. For these reasons, the requested Forfivo XL 450 mg is medically necessary for treatment of this patients attention deficit hyperactivity disorder (ADHD). 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 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: A patient has requested authorization and coverage for Entyvio infusion treatments (J3380) every four weeks (300 mg for a total of six visits given over 27 weeks). The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients ulcerative colitis (UC). The submitted documentation supports the medical necessity of the requested medication regimen. The study by Loftus and colleagues showed that patients with ulcerative colitis who had lost response to Entyvio every eight weeks regained response with  four-week dosing in a significant fraction of cases. Other studies have shown similar improvement. In this case, the patient had some residual colonic inflammation on colonoscopy even after increasing to Entyvio every four weeks. A change back to Entyvio every eight weeks, or a change to an alternative therapy, may result in worsening disease or disease complications such as disease flare, toxic megacolon, need for hospitalization, or need for a surgery. For these reasons, Entyvio infusion treatments (J3380) every four weeks (300 mg for a total of six visits given over 27 weeks) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronan (Supartz) injections every six months. There is sufficient support for the requested services in this clinical setting. The evidence-based literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. In this case, the patient has been diagnosed with bilateral knee osteoarthritis. He reports significant functional limitations in ambulation, exercise tolerance and work activities. Conservative treatment has included activity modification, bracing, and medications, without adequate relief. He has received multiple series of Supartz injections to both knees that have provided significant pain relief and functional restoration allowing for work and activities of daily living for at least six months over the past five years. Therefore, the requested hyaluronan (Supartz) injections every six months 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.