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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for bilateral mastectomy for treatment of his gender dysphoria. Findings: The physician reviewer found that the documentation provided supports the requested procedure in this clinical setting. Each patient must be reviewed on a case-by-case basis to determine medical necessity. This patient has gender identity disorder and is transitioning to a male. He has evidence of abnormal breasts for a male despite the use of hormonal therapy. This medical condition would not likely resolve with continued hormonal therapy. While the Health  In this patients case, his breasts appear to be consistent with a teenage female. Hormone therapy will unlikely resolve this patients breast enlargement.  Since the condition will not resolve even with hormone therapy, surgical intervention to treat this patients dysphoria is medically reasonable and appropriate.  All told, this patient has evidence of abnormal breasts for a male and his medical condition will not likely improve with continued hormonal therapy. Therefore, bilateral mastectomy is medically necessary for the treatment of this patients gender dysphoria. With regard to whether the requested procedure is considered reconstructive in nature, the submitted documentation reveals that the patients breasts constitute an abnormal structure of a male body. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be performed to approximate a normal appearance. The patients breasts should be more consistent with male breasts. Based on the patients gender dysphoria and identification as a male, a normal appearance of the breasts for a male is the ultimate goal. In this patients case, he has evidence of abnormal breasts for a male. The goal of the surgery is to create a more normal appearing male chest and offer a more than minimal improvement in the appearance of the patient. All told, in this patients case, bilateral mastectomy is reconstructive in nature.  Final Result: The reviewer determined that the requested procedure is medically necessary and is reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Sovaldi and Zepatier for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), Deferral of treatment is recommended, pending availability of data for patients with HCV genotype 1, regardless of subtype, in whom previous treatment with any HCV nonstructural protein 5A (NS5A) inhibitors has failed, who do not have cirrhosis, and do not have reasons for urgent retreatment. In this case, the patient does not have cirrhosis, and no other reason for urgent re-treatment compatible with the high-urgency group in the guidelines is provided. Even if re-treatment were necessary per the guidelines, the requested regimen would not be appropriate, as after failure of an NS5A inhibitor such as Harvoni, the Sovaldi, Zepatier and ribavirin regimen is only recommended by the guidelines when resistance to both NS5A and nonstructural protein 3 (NS3) inhibitors is present. In this case, NS5A resistance is present, but NS3 resistance testing is not provided. For these reasons, the request for Sovaldi and Zepatier is not supported as medically necessary for the re-treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an esophageal sphincter augmentation device for treatment of the enrollees gastroesophageal reflux disease. Findings:  2/3 of the physician reviewers found that 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. Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. For these reasons, the requested esophageal sphincter augmentation device is not likely to be of greater benefit than other available treatment alternatives.  Final Result: 2/3 of the 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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 Epclusa for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive, genotype 2 patients.  A delay in treatment may result in decreased survival. For these reasons, Epclusa 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: The parent of a male enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of direct applied behavior analysis (ABA) therapy, eight hours per week of supervision, and three hours per week of parent training, for six months for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that ABA is a medically necessary intervention for the treatment of autism spectrum disorders, and remains one of the most evidence-based interventions available. In this case, the patients family is requesting continued coverage of ABA therapy to address delays in adaptive, social, behavioral and communication skill sets. A treatment plan has been developed that is consistent with the patients essential health needs. ABA as a treatment is evidence-based and scientifically proven to be effective. The purpose of ABA in this case is to promote independence for the patient by addressing current deficits.  The correlation between treatment outcomes and treatment intensity is well-documented. In a recent article on the efficacy of ABA published by colleagues, the authors noted a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. In this article, 726 children were studied and were shown to make increased progress towards learning objectives with increased intensity of treatment. Up to this point, the patient appears to have made progress in many areas, but he continues to demonstrate significant delays in social skills and adaptive skillsets as measured across multiple domains as well as severe behaviors (elopement and aggression).  He continues to require a high level of behavioral support.  Failure to master these skills not only puts the patient at an increased risk for injury, but also makes it increasingly difficult to be successful in more generalized environments. The current medical evidence supports the services at issue in this clinical setting.  All told, 40 hours per week of direct applied behavior analysis (ABA) therapy, eight hours per week of supervision, and three hours per week of parent training, for six months were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 sub-specialty certification 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 botulinum toxin (Botox) for treatment of the enrollees chronic headaches. Findings:  The physician reviewer found that the medical literature supports the medical necessity for the requested medication in this clinical setting. This patient has well documented record of migraines, and has tried and failed the medication topiramate. Per the International Headache Society classification of headache disorders, chronic migraine is defined as greater than 15 headache days per month for greater than three months, headache is not attributable to another disorder, at least two characteristics of unilateral, pulsatile, moderate to severe in intensity, or aggravation by or causing avoidance of routine physical activity. Additionally, there must be one characteristic of nausea and/or vomiting, photophobia and phonophobia. Botox is a tool in the management of chronic migraine which has shown effectiveness. Significant reductions from baseline were observed for onabotulinumtoxinA for headache and migraine days, cumulative hours of headache on headache days and frequency of moderate/severe headache days, which in turn reduced the burden of illness in adults with disabling chronic migraine. Concluded that onabotulinumtoxinA is effective for prophylaxis of headache in adults with chronic migraine. Repeated onabotulinumtoxinA treatments were safe and well tolerated.  As a result of these studies, Botox has been approved by the U.S. Food and Drug Administration for use in prophylactic management in chronic migraine. In addition to Botox, the only prophylactic medication that has been shown to be effective is topiramate in the management of chronic migraine. Considering the reported trial and failure of topiramate, Botox would be the most appropriate next step in the management of this patient for chronic migraine. Therefore, in this patients case, botulinum toxin (Botox) is medically necessary for treatment of this patients medical condition.  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 with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 3a. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa is recommended as a first-line regimen for non-cirrhotic treatment naive genotype 3 patients. This is based on the trial for Epclusa, which showed a high cure rate of 98%. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Epclusa 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services for treatment of the enrollees alcohol abuse and bulimia. Findings:  The physician reviewer found that based on the records provided for review, the RTC services provided were not and are not medically necessary for treatment of this patients medical condition. The patient denied suicidal or homicidal ideation, and she was not self-harming. She had gained 7.3 pounds, placing her at 92% of her ideal body weight (IBW) and had a BMI of 20.5. She had eating disorder urges but did not show any behaviors. She required supplementation, but her compliance and intake were high. Her gastrointestinal symptoms, medications, and continued substance abuse recovery did not require treatment at the RTC level of care. Her eating disorder no longer required 24-hour medical and nursing supervision. She could have been stepped down to an ambulatory level of care such as partial hospitalization program (PHP). Thus, the services at issue were not and are not medically necessary. Final Result: The reviewer determined that the services at issue were not and are 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 psychiatry with sub-specialty certification in addiction 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Concerta 54 mg twice per day for treatment of the enrollees attention deficit hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that according to the U.S. Food and Drug Administration (FDA), the maximum dosage for Concerta for children and adolescents is 72 mg per day. There are limited studies supporting the use of doses above 72 mg per day in adolescents. Due to the lack of peer-reviewed literature supporting Concerta with doses above 72 mg per day, Concerta 54 mg twice per day is not clinically indicated. Therefore, the request for Concerta 54 mg twice per day is not medically necessary for treatment of the patients ADHD. Final Result: The reviewer determined that the requested medication dosage 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 psychiatry with sub-specialty certification in 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program services for three days per week for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The patient has struggled with mental health issues since early childhood.  He suffers from a serious formal thought disorder and has the added complications of depression, anxiety and social isolation.  The patients illness burden has necessitated the full-range of treatment interventions over the years, including the prescription of complex pharmacotherapy.  Considering this patients improvement with the intensive outpatient program and degree of psychiatric impairment in the past eight months in context of nearly lifelong mental illness, a conservative intensive outpatient program admission is likely to provide the best chance for a successful transition to a less restrictive setting.  The intensive outpatient program setting remains safe, appropriate, consistent with good medical practice, and is reasonably expected to both improve the patients condition and prevent a more serious episode of illness.  Thus, intensive outpatient program services for three days per week were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan with computed tomography (CT) for attenuation for evaluation of the enrollees neuroendocrine tumor. Findings:  The physician reviewer found that Neuroendocrine tumors develop in hormone-producing cells of the bodys neuroendocrine system, and are located in organs such as the stomach, intestines, pancreas, and lungs. Neuroendocrine tumors have receptors for somatostatin, a hormone that regulates the endocrine system. Gallium 68-dotatate is a positron emitting analogue of somatostatin. The uptake of gallium 68-dotatate reflects the level of somatostatin receptor density in neuroendocrine tumors. As such, it can be used to guide diagnosis, staging, and treatment management. Current studies have demonstrated that it be used in patients with prior diagnosis and not in patients presenting with symptoms alone as the diagnosis rate in this scenario is 1%. The standard modality is using the In-pentetreotide scan. A study was performed which demonstrated that of 78 patients who underwent ln-pentetreotide scan and a PET with gallium 68-dotatate, changed care in 28 patients, with a major change for 19 patients because additional metastatic disease was detected. This study reported that ln-pentetreotide lacked uniform quality and exposed patients to a higher level of radiation. The National Comprehensive Cancer Network (NCCN) guidelines recommend that a somatostatin analog based imaging study be performed at the time of initial diagnosis and re-staging or evaluation of tumor burden. Given that the PET scan with gallium 68-dotatate has been demonstrated to be superior in diagnosing and staging neuroendocrine cancers, the request for PET scan with CT for attenuation has been established medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical 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.