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

Nature of Statutory Criteria/Case Summary: An enrollee was diagnosed with childhood onset gender dysphoria. The patient transitioned socially and was started on hormone suppression. She began estrogen treatment. One provider reports that the patient has demonstrated improved mood and increased happiness with each step of her transition. The patient has experienced ongoing and persistent symptoms of gender dysphoria. The patient is seeking vaginoplasty surgery with the support of her parents. She is stable on current hormonal treatment and there is no evidence of any mental health or medical barriers to the surgery. At issue in this case is whether intersex surgery (vaginoplasty commonly known as MTF bottom surgery) is medically necessary for the treatment of the patients medical condition. Genital surgery is often the last, and the most considered step in the treatment process for gender dysphoria. According to the World Professional Association for Transgender Health (WPATH), relief from gender dysphoria cannot be achieved without modification of the patients primary and secondary sex characteristics to establish greater congruence with their gender identity. In this case, the patient has a diagnosis of gender dysphoria that has persisted through puberty. The patient transitioned from male to female (MTF) several years ago with hormone suppression and estrogen. In addition, multiple evaluations from medical and mental health professionals, as well as letters from her parents and grandparent, state that the patient has successfully transitioned to female in all aspects of her life. Therefore, intersex surgery (vaginoplasty commonly known as MTF bottom surgery) is medically necessary for the 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 psychiatry with subspecialty 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: The patient has requested authorization and coverage for the Aimovig autoinjector. In the current peer-reviewed medical literature, Weatherall noted that chronic migraine is a condition characterized by the experience of migrainous headache on at least 15 days per month, is highly disabling. This patients records document 15-20 migraines per month despite treatment with rizatriptan, sumatriptan, Tylenol, Excedrin, Advil and Topamax. However, the patient reported excellent results with Aimovig with a decrease to only two to three migraines per month. Goadsby and colleagues concluded that Aimovig administered subcutaneously at a monthly dose of 70 mg or 140 mg significantly reduced migraine frequency, the effects of migraines on daily activities, and the use of acute migraine-specific medication over a period of six months. There is documentation that this patient has failed three migraine prophylactic treatments over the course of three years. Moreover, there is an adequate scientific and medical basis for the utility of the Aimovig autoinjector in this clinical setting. Given this support, the Aimovig autoinjector is medically necessary for treatment of this patients migraine headaches.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for Cornea Collagen Crosslinking. The scientific literature noted improvement in visual acuity after undergoing the collagen crosslinking procedure. It was concluded that the collagen crosslinking procedure is a safe and effective method for halting the deterioration of keratoconus. The Food and Drug Administration (FDA) approved corneal crosslinking for the treatment of patients with progressive keratoconus in 2016. This procedure was effective in improving vision in eyes with progressive keratoconus 1 year after treatment, with an excellent safety profile. Corneal collagen crosslinking provides the keratoconic patient with an important new option to decrease progression of this ectatic corneal processFinal Result: Three of the three reviewers determined that the requested service is likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is overturned.Credentials/Qualifications: Three reviewers are board certified in Ophthalmology 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: An enrollee has requested authorization and coverage for a six to eight week program at a residential treatment center that specializes in posttraumatic stress disorder caused by childhood trauma. The progress notes indicate the patients main problems are due to family relationship issues as well as depression and anxiety. The patient denied a history of suicide attempts and does not have active substance use issues. In cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. With regards to risk of harm, the records support a score of 2 due to a lack of current suicidal ideation and no history of suicide attempts. In terms of functional status, the records support a score of 3 due to significant inability to maintain family relationships with no indication of difficulties with activities of daily living. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 2 due to medical issues which are under control and no current substance use. In terms of level of stress of the recovery environment, the records support a score of 2 due to a stable living environment and no financial stressors. With regards to level of support of the recovery environment, the records support a score of 2 due to a positive relationship with her spouse. In terms of treatment and recovery history, the records support a score of 3 due to minimal treatment in the recent past and unclear response to recent medication treatment. With regards to engagement and recovery status, the records support a score of 3 due to cooperation in treatment and only limited insight into the need for treatment. Thus, the patient has a composite score of 17. This score correlates with high intensity community-based services. Therefore, a six to eight week program at a residential treatment center that specializes in posttraumatic stress disorder caused by childhood trauma is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 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 patient has requested authorization and coverage for genetic testing (CPT codes 81243, 81412, and 81443). Cell-free fetal DNA-based prenatal testing through panels of syndromes based on ethnic backgrounds is indicated when the disorders included in panel testing are associated with ethnic-based syndromes that meet current consensus to be included in carrier screening. According to the American College of Obstetricians and Gynecologists (ACOG), these criteria used to include conditions that: have a carrier frequency of 1 in 100 or greater; have a well-defined phenotype; have a detrimental effect on quality of life; cause cognitive or physical impairment; require surgical or medical intervention; or have an onset early in life. Additionally, screened conditions should be able to be diagnosed prenatally and may afford opportunities for antenatal intervention to improve perinatal outcomes, changes to delivery management to optimize newborn and infant outcomes, and education of the parents about special care needs after birth. Further, ACOG has recommended offering carrier screening for four conditions in the Ashkenazi Jewish population including Canavan disease, cystic fibrosis, familial dysautonomia, Tay-Sachs. Furthermore, some experts have advocated for a more comprehensive screening panel for those of Ashkenazi Jewish descent, including tests for several diseases that are less common. This patient is noted to be of Ashkenazi Jewish descent and has a family history of Gaucher disease. Based on these findings, the requested genetic testing (CPT codes 81243, 81412, and 81443) is likely more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology with subspecialty certification in maternal and fetal medicine 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: An enrollee has requested authorization and coverage for Estrogel 1.25 gram/actuation 0.06% gel. Findings:  The physician reviewer found that the requested medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.The medical evidence supports the requested medication in this clinical setting. Per the current literature, systemic estrogen replacement therapy is the most effective treatment for menopausal symptoms. Estrogel is effective for the treatment of postmenopausal vasomotor symptoms. The enrollee has tried other formulations of estrogen/hormone replacement therapy, but these treatments have been ineffective. Estrogel has been approved by the U.S. Food and Drug Administration for the treatment of postmenopausal symptoms. Therefore, Estrogel 25 gram/actuation 0.06% gel is medically necessary for the treatment of this enrollee. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: Enrollee requested Orthovisc (hyaluronan) injections in both knees for treatment of osteoarthritis of both knees.  Findings:  The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.At issue in this case is whether the requested Orthovisc (hyaluronan) injections in both knees is medically necessary for the treatment of the enrollees medical condition. The enrollee has a history of osteoarthritis of both knees with complaints of bilateral knee pain. Enrollee failed conservative treatment. Enrollee received Orthovisc injections with good benefit lasting one to one and a half year.Current evidence is limited, and guidelines from reputable organizations indicate that the evidence is inconclusive.  As such, the organization does not currently support viscosupplementation as the standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can be recommended in enrollees with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. The enrollee benefited from prior injections. Her options are limited, as the alternative is a total knee arthroplasty. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for Hyperbaric Oxygen Therapy for treatment of pyoderma gangrenosum. The scientific literature indicates there is still no general agreement on the medical and surgical treatment of this condition. Data are insufficient to recommend the routine use of this therapy. Further studies are needed for this diagnosis.  Most studies have been small.  For these reasons, hyperbaric oxygen therapy is not likely to be more beneficial than any available standard therapy.Final Result: Three of the three reviewers determined that the requested service is not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is upheld.Credentials/Qualifications: Three reviewers are board certified in Dermatology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization for a PET scan with CT for Attenuation. Findings: Three of the three physician reviewers agreed to uphold the Health Plans decision to deny the authorization according to the patients medical records and supportive literature including evidence from the American College of Radiology (ACR) and National Comprehensive Cancer Network (NCCN). PET scanning is a new modality and many questions as to the appropriateness and clinical benefit remain. It is not at all certain that using PET in gallbladder cancer results in clinically beneficial decisions and false positive and false negative rates have not been adequately studied. Based on the medical literature, there is no evidence that PET/CT is likely to be more beneficial than conventional imaging for patients with metastatic gallbladder cancer.  While gallbladder cancer can be assessed with PET/CT, there is no clinical trial that has shown PET/CT to be more beneficial in comparison to conventional imaging with CT or MRI.According to the National Comprehensive Cancer Network (NCCN), PET/CT may be useful for predicting prognosis, such as overall survival and disease free survival, but it is associated with low sensitivity for hepatocellular cancer. Final Result: The reviewers determined that the requested service is not likely to be more beneficial than conventional imaging with CT or MRI.  Credentials/Qualifications: Physician reviewer 1 is board certified in Hematology & Medical Oncology and is actively practicing. Physician reviewer 2 is board certified in Hematology & Oncology and is actively practicing. Physician reviewer 3 is board certified in Oncology. 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The patient has severe pain from osteoarthritis of  both knees. Based on the current medical studies, hyaluronic acid is no longer recommended for patients with symptomatic osteoarthritis. Scientific evidence indicates there are currently no clinical indications for this technology and strongly do not recommend use. Final Result: The reviewer determined that the service at issue was not medically necessary for treatment of the patients condition.  Therefore, the health plans denial was upheld.Credentials/Qualifications: The physician reviewer is board certified in Orthopedic Surgery and is actively practicing.