Persius/hicric huggingface dataset:
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 laser hair removal. Findings:  The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition in this clinical setting. Facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. Excessive facial hair in a female would be considered abnormal and is referred to as hirsutism. Hirsutism is a medical diagnosis where terminal hair grows in female in areas that are normally found in males. This would include the face and parts of the genitalia. A female would be expected to have terminal hair in the scalp, axilla and on the arms and legs. This patients excessive facial hair is more consistent with the male gender. Additionally, hormone therapy has not been effective in improving this patients medical condition. Therefore, facial hair removal is medically necessary for the treatment of this patients gender dysphoria.With regard to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is an abnormal body structure.  Hirsutism is a condition that is congenital in that the hair growth is determined by the genetic and hormonal makeup of the patient. As such, the requested facial hair removal can provide a minimal improvement in the appearance of terminal hair and create as normal an appearance as possible in this patient. Moreover, the requested services are going to improve emotional function for this patient. All told, laser hair removal is reconstructive in nature.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The 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 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 compound medication (progesterone micronized 100% powder) provided Findings:  The physician reviewer found that the physician reviewer found that progesterone supplementation is routinely used in assisted reproduction to increase pregnancy success rates.  In this case, the patient was of an advanced maternal age and attempted pregnancy via embryo transfer. As noted by a study, there is little doubt that endometrial receptivity plays a major role in the success or failure of embryo implantation after in vitro fertilization (IVF). To optimize endometrial receptivity, it is common practice to administer a progesterone supplement during the luteal phase. Thus, treating this patient with micronized progesterone was medically appropriate. In this patients case, the provider recommended micronized progesterone suppositories, and there are no prescription suppositories currently manufactured by a pharmaceutical company.  The medical evidence supports the medication at issue in this clinical setting. All told, compound medication (progesterone micronized 100% powder) provided during the dates of dispute was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was 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 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services.Findings:  The physician reviewer found that the services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented with a gradual decompensation of his PANDAS condition, demonstrating a decrease in cognitive function and school performance, with an inability to focus, worsening fatigue, increase in tics, and increase in obsessive compulsive tendencies. The standard of care for managing PANDAS exacerbation, includes obtaining the Cunningham Panel for diagnostic purposes and administration of IVIG. The Cunningham Panel provided, met the criteria for emergency medical services. The Cunningham Panel showed abnormal findings for anti-D1 receptor, which is twice the level of normal and abnormal level of calmodulin kinase II, which is 155% of normal. The laboratory abnormalities were evidence of disruption of the blood-brain barrier and were indicative of substantial elevation of inflammation in the basal ganglia, therefore representative of an exacerbation in PANDAS condition and neuroinflammation. Moreover, the return of specialty labs and review of those findings and discussion about the next level of care can take a period of time.  It is typically usual to have a minor delay in time for this review and discussion between provider and patient to occur.  As such, the IVIG services provided were emergent. For the reasons provided, emergency medical services provided were necessary for an emergent medical condition.Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in allergy and immunology 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 an enrollee has requested reimbursement and prospective authorization and coverage for speech therapy services and future services for treatment of the mixed receptive-expressive language disorder. Findings:  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the services at issue. The US Preventive Services Task Force support speech therapy services for children with speech language delays.  The meta-analysis performed by researchers found that longer duration of speech therapy was associated with improvements, and evidence of improvements in expressive language with speech therapy.  Per the results from Rossetti Infant-Toddler Language Scale testing, the patient has considerable speech delay with skills at the nine to 12 month age level at the age of 21 months. In addition, the patient is now 27 months and only utilizes five words. All told, speech therapy is clinically indicated for treatment of the patients moderate speech language delay.  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 and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha Sureclick 140 mg/ml subcutaneous pen injector for treatment of the enrollee who has a history of carotid stenosis and coronary heart disease.  Findings:  The physician reviewer found that the documentation provided does not support the requested medication in this patients case. Based on the records provided, the patient has documented coronary vascular disease. There is no confirmed intolerance to statin medications in the documentation since there is no documented elevated muscle enzymes, elevated liver enzymes or transient worsening symptoms while on statins. In addition, the patients weakness may be due to his confirmed diagnosis of inclusion body myositis.  Moreover, there is no documented trial or intolerance of Zetia, a nonstatin medication that has been demonstrated to improve cardiac outcomes in patients with documented coronary disease. Additionally, there is no documented history of heterozygous or homozygous familial hyperlipidemia. Therefore, based on the records provided Repatha Sureclick 140 mg/ml subcutaneous pen injector is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication 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 internal medicine with sub-specialty certification in cardiovascular disease 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 emergency medical services. Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of an emergency medical condition. The documentation submitted for review does not demonstrate evidence of an emergency medical condition. The medical records provided for review, fail to show past medical history addressing a mechanism of injury leading to the reported acute presentation or evidence of chronicity. In addition, there is no documentation of imaging to rule out underlying injury/pathology that would lead to the reported emergency presentation. Therefore, the services provided are not considered emergency medical services. Thus, the patient did not receive emergency medical services on the date 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 oriental medicine and chiropractic 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 reimbursement for monitored anesthesia care for treatment of the enrollee, who underwent a colonoscopy. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue in this patients case. Colonoscopies are commonly performed with propofol sedation. The propofol package insert requires that a professional trained in anesthesia be present when propofol is being used. This patient underwent a colonoscopy, and the medical evidence supports monitored anesthesia care in this clinical setting. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 laboratory testing for evaluation of the enrollees non-small cell lung carcinoma. Findings:  Two physician reviewers found that the National Comprehensive Cancer Network (NCCN) guidelines believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.  The NCCN guidelines for non-small cell lung cancer strongly endorse broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients who are diagnosed with non-small cell lung cancer. Multiplexed genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially one by one. This is one of the most tissue efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time efficient process for screening patients, thus  facilitating  prompt treatment or protocol inclusion. For the treatment of patients with advanced non-small cell lung cancer, broad molecular profiling, such as with Guardant360 testing, is considered a standard of care. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the Praluent Pen 75 mg/mL every two weeks. Findings:  The physician reviewer found that based on the records provided for review, this patient presents with known obstructive coronary disease, dyslipidemia and documented intolerance to multiple statin medications and ezetimibe. Praluent is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol despite maximal tolerated statin and ezetimibe. This patient meets the criteria for treatment since there is a documented clinical coronary disease and intolerance to statin medications and ezetimibe. In this clinical setting, PCSK9 inhibitors have been demonstrated to be safe, effective in lowering cholesterol and are associated with a significant reduction in adverse cardiac events in prospective randomized trials. Given these findings, the requested Praluent Pen 75 mg/mL every two weeks 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 test for evaluation of the enrollees non-small cell lung carcinoma. Findings:  Two physician reviewers found that the Guardant360 test is a liquid biopsy that analyzes patient plasma for mutations. Researchers performed a clinical study directly comparing the use of targeted agents with conventional chemotherapy approaches. The study involved 86 patients where the progression free survival on regimen selected by molecular profiling was compared to the progression free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial has very significant results for patients with stage IV tumors. The results from molecular profiling offers a rational selection for this patients next regimen. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cosentyx for treatment of the enrollees plaque psoriasis. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. In this case, the patient has chronic plaque psoriasis and has failed many standard therapies. Light therapy requires three times weekly treatment and this patient would have to drive over 60 miles to get treatment three times a week, which is not reasonable for a five minute treatment. In addition, the use of cyclosporine is not medically appropriate to be used long-term for control of a chronic plaque psoriasis. Also, the patient has elevated lipid levels and is treated with Lipitor. Treatment with acitretin is contraindicated for this patient as acitretin is known to have frequent side effects for patients with elevated lipid levels. Lastly, since the patient regularly consumes alcohol, treatment with Cosentyx is medically appropriate given that the patient will not have an adverse effect on the liver that may occur with methotrexate. 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a transgender male enrollee has requested authorization and coverage for bilateral breast mastectomy. 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. The patients age should not be used as a sole determinant for medical necessity. He has evidence of abnormal breasts for a male despite the use of hormonal therapy. The examination noted the patient has full female breasts with grade II ptosis. This medical condition would not likely resolve with continued hormonal therapy. Although this patient is a minor, chronological age is not as important as the level of pubertal development. 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 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 breast mastectomy is medically necessary for the treatment of this patients gender dysphoria. With regards to whether the requested procedure is considered reconstructive in nature, the submitted documentation reveals that the patients breasts constitute an abnormal structure for 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. As such, in this patients case, bilateral breast 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.