Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: At issue is whether the DaT scan was likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy. A review of the records indicated that the patient presented with a history of right extremity upper tremor, rigidity, and clumsiness. The provider documented concern for Parkinsons disease. Previous trials with Sinemet and Ropinirole were unsuccessful due to side effectsFindings:  Two out of three physician reviewers found that in this case, the patients movement disorder specialist did not order the scan for three years after presentation as the patient progressed. The presentation of the patients symptoms was not typical due to the lack of the therapeutic response to dopaminergic agents. Therefore, the DaT scan was likely to have been more beneficial for the evaluation of the patients medical condition than other standard techniques. One out of three physician reviewers found that the management of this patient's symptoms could have otherwise been addressed with the introduction of pharmacotherapy, and this could occur without performance of a DaT scan. Therefore, the DaT scan that was rendered was not likely to have been more beneficial than other methods of evaluating this patient.Final Result: Two out of three of the reviewers determined that the requested DaT scan provided was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested regenerative stem cell therapy, Dilantin and ketamine. With regard to the request for regenerative stem cell therapy, a review of records document this patient has been diagnosed with bilateral hip and knee osteoarthritis and chondromalacia patella of the left knee. He reports severe and functionally limiting hip and knee pain. However, detailed evidence of a recent comprehensive non-operative treatment protocol trial and failure has not been provided for review. In addition, current evidence-based medical guidelines and peer-reviewed literature indicate that stem cell therapy has not been proven to be safe and effective for treatment of osteoarthritis. Studies noted that studies of intra-articular cellular therapy injections for osteoarthritis suggested positive results relative to clinical improvement and safety, but more standardization and higher quality research was needed before any broad scale recommendation can be made. In addition, studies concluded that large, randomized, placebo controlled studies with long-term follow-up are lacking to evaluate the effectiveness of regenerative stem cell therapy in this clinical setting. Thus, the requested regenerative stem cell therapy is not medically necessary for treatment of this patients medical condition.Phenytoin sodium (Dilantin) is used to control certain type of seizures, and to treat and prevent seizures that may begin during or after surgery to the brain or nervous system. Phenytoin is in a class of medications called anticonvulsants which work by decreasing abnormal electrical activity in the brain. Studies noted that phenytoin has been explored in over 100 different disorders with promising indications for breast cancer and optic neuritis. This patients records do not include evidence of a seizure disorder or other indication for Dilantin. Therefore, Dilantin is not medically necessary for treatment of this patient.Ketamine is a parenterally administered, general anesthetic primarily used for short-term diagnostic and surgical procedures, but its use is limited due to its psychological side effects including vivid hallucinations, agitation and confusion. A review of the patients records did not reveal an indication for ketamine. Further, the patients provider noted that ketamine was not recommended at this time. Therefore, the request for ketamine is not medically necessary.Final Result: The reviewer determined that the requested services and 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 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: The patient has requested reimbursement for reduction mammoplasty. The Health Plan has denied this request and reported that the services at issue were not medically necessary and were not reconstructive in nature. At issue in this case is whether reduction mammoplasty was medically necessary to treat the patients medical condition.Findings:  The physician reviewer found that the American Society of Plastic Surgeons (ASPS) states that reduction mammoplasty should be based on documentation of the severity of the symptoms of macromastia and impact on health-related quality of life with at least two of the following signs: chronic breast pain due to weight of the breast, intertrigo unresponsive to medical management, upper back, neck, and shoulder pain, unspecified, thoracic kyphosis, acquired, shoulder grooving from bra straps, upper extremity paresthesia due to brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area, headache and congenital breast deformity.In this case, the patient reported back, shoulder and neck pain, and shoulder grooving is documented in the submitted photographs. There is no report of chronic breast pain due to weight of the breasts, intertrigo unresponsive to medical management, thoracic kyphosis, upper extremity paresthesia, headache, or congenital breast deformity. Since there are at least two quality of life signs, the requested reduction mammoplasty was medically necessary for the treatment of this patients medical condition. The condition of breast hypertrophy is an abnormal structure of the body caused by a developmental abnormality. The reduction mammoplasty was performed to improve function of the body. The reduction mammoplasty was likely to have offered more than a minimal improvement in the appearance of the patient. Therefore, the reduction mammoplasty performed was reconstructive in nature.Final Result: The reviewer determined that the requested services 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 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 the brand name medication Remeron and the brand name medication Zoloft. The submitted documentation fails to demonstrate the medical necessity of the requested medications. This patients providers have opined that brand name medications are not medically necessary. The patient has made the claim that he is allergic to all generic medications. His providers have opined that there is no medical condition which would cause a patient to be allergic to all generic medications. The U.S. Food and Drug Administration (FDA) has indicated that generic medications and brand name medications have similar efficacy. The medical records do not contain progress notes which document the patients reported adverse effects. There is a lack of objective evidence in the medical records to indicate that the patient has had adverse effects from generic medications. Therefore, the brand name medication Remeron and the brand name medication Zoloft are not medically necessary for the treatmetn of this patient. 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 psychaitry 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: This patient is a 61-year-old female diagnosed with post-menopausal osteoporosis w/o fracture. Findings:  The physician reviewer found that a dual-energy x-ray absorptiometry (DEXA) scan obtained showed a left hip T score of -1.4 and a spine T score of -2.5. An x-ray of the left hip performed revealed moderate left hip osteoarthritis and less severe osteoarthritis of the right hip. Laboratory results showed normal creatinine levels and kidney function. The patient has been treated with physical therapy, Citracal, and vitamin D. Actonel was discontinued in January 2019 due to heartburn. Physical examination findings  included limited range of motion in the left hip. The patient has requested reimbursement and prospective coverage for denosumab (Prolia) that was provided very six months. The Health Plan denied the request and reproted the Prolia was not and is not medically necessary for the treatment of this patient. At issue in this case is whether Prolia that was administered and forward, every six months was and/or is medically necessary for treatment of the patients medical condition. The patients fracture risk assessment tool (FRAX) score indicates a 10-year risk of fracture. Management of postmenopausal osteoporosis includes bisphosphonates, which are considered first-line treatment. The patient reported heartburn while taking an oral bisphosphate. Guidelines recommend intravenous bisphosphonates when oral bisphosphonates cannot be tolerated Prolia may cause hypocalcemia, serious skin infections, skin rash or osteonecrosis of the jaw and atypical femur fractures. Data suggests that when Prolia treatment is stopped, bone loss can be rapid As this patient has normal kidney function and is not at high risk for fracture, intravenous bisphosphonates are the preferred agents for treatment. Therefore, the Prolia that was received on 2/9/19 and forward, every six months, was not and is not medically necessary for treatment of this patient.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 allergy and immunology and internal medicine with a subspecialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 57-year-old male with a history of osteoarthritis of the left knee requested authorization and coverage for hyaluronan injections for the left knee.A review of medical literature reveals mixed results. Researchers conducted a literature review to determine the strength of evidence in support of the efficacy of intra-articular hyaluronan acid (IAHA) injections from randomized controlled trials and meta-analyses. The analysis showed that IAHA provided a moderate symptomatic benefit to patients with knee osteoarthritis without major safety concerns. IAHA may offer one of the best benefit-to-risk ratios among pharmacologic options, as measured by improvements in knee osteoarthritis health outcomes, overall gain in quality-adjusted life years and substantial delays in time to total knee replacement. Researchers review of literature noted that meta-analysis of double-blinded sham controlled trials with at least 60 patients did not show clinically important differences of treatment with IAHA over placebo. Researchers noted that in a randomized double-blind comparison of treatments with IAHA and triamcinolone, IAHA increased functional scores but was not superior to the use of triamcinolone.  This patient has a history of osteoarthritis of the left knee, which has failed to improve despite treatment with arthroscopic surgery, bracing, intra-articular corticosteroid injections, low impact exercise and medications. In this case, the options are limited, and the purpose of current treatment is to relieve pain and postpone a total knee arthroplasty. As such, the requested hyaluronan injections for the left knee are medically necessary.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 orthopaedic 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: The patient is a 55-year-old female with past medical history of hypertension and insomnia. She has taken zolpidem and requested a refill of zolpidem. The medical record does not document any non-pharmacologic management of insomnia and documents use of caffeine in the form of coffee. The provider documented a review of controlled substance utilization, review and evaluation system (CURES), which showed that the patient had obtained a zolpidem prescription from another provider. The provider documented that ongoing use of zolpidem was not recommended and that a non-controlled medication such as trazodone should be considered. At issue is whether zolpidem is medically necessary for treatment of this patient.Appropriate management of chronic insomnia includes therapy for any conditions that affect sleep quality or duration and behavioral recommendations for sleep hygiene and stimulus control. Behavioral therapies, including cognitive behavioral therapy, is recommended as first-line therapy. Pharmacologic therapy may be indicated when insomnia persists despite sleep hygiene, including avoidance of caffeine, and adequate behavioral therapy. Long-term treatment with medication alone is not the optimal treatment strategy for patients with insomnia. In this case, the patient has a diagnosis of insomnia that has been treated with long-term use of zolpidem. The provider recommended changing zolpidem to a non-controlled medication such as trazodone. The records do not suggest adherence to a sleep hygiene plan given the continued use of caffeine, and there is no documentation of trial of behavioral therapy. Therefore, the requested zolpidem is not medically necessary for treatment of the 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 family 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 facial feminization surgeries. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. The requested services are likely to benefit this patients psychological and social functioning. This patient has a documented history of gender dysphoria and has been through other medical therapies. The World Professional Association for Transgender Health (WPATH) stated medically necessary gender affirming/confirming surgical procedures include complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient, including nipple resizing or placement of breast prostheses, as necessary; genital reconstruction by various techniques which must be appropriate to each patient, including, for example, skin flap hair removal, scrotoplasty, and penile and testicular prostheses, as necessary; facial hair removal, certain facial plastic reconstruction, voice therapy and/or surgery, and gender affirming counseling or psychotherapeutic treatment, as appropriate to the patient. The Transgender Medicine Model NCD Working Group noted other surgeries or procedures that may be necessary to resolve gender dysphoria and allow transgender women to navigate the world as women includereconstructive facial feminization surgeryThese procedures are not cosmetic, but rather serve a primarily reconstructive purpose by allowing transgender women whose overall physical appearance otherwise prevents them from being perceived as female. Based on the patients documented history of gender dysphoria, the requested services are medically indicated. Therefore, facial feminization surgeries 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the brand name medication Flomax. The submitted documentation fails to demonstrate the medical necessity of the requested medication. When a generic drug product is approved by the U.S. Food and Drug Administration (FDA), it has met rigorous standards established by the FDA with respect to identity, strength, quality, purity and potency. Generic drugs are required to have the same active ingredient, strength, dosage form and route of administration as the brand name product. Through review of bioequivalence data, the FDA ensures that the generic product performs the same as its respective brand name product. This standard applies to all generic drugs, whether immediate or controlled release. In this case, the records do not document that the patient has had a significant adverse reaction to the generic drug tamsulosin. The efficacy of both the brand name and generic drug are equivalent. Therefore, the brand name medication Flomax is not medically necessary for the treatment of this patient. 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 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 is a male diagnosed with osteoarthritis of both knees.  He has failed treatments, which has included anti-inflammatory medication, bracing, and corticosteroid injections. The patient prefers to delay surgical treatment and has benefitted from viscosupplementation in the past. The most recent Orthovisc injections were administered to both knees and provided pain relief. The patient has requested coverage for a Monovisc injection. The Health Plan denied the request and reported that the requested treatment was not medically necessary for the treatment of this patient. At issue in this case is whether a Monovisc injection is medically necessary for the treatment of the patients medical condition. Intra-articular hyaluronic acid injections provide a symptomatic benefit for patients with knee osteoarthritis without major safety concerns.  Viscosupplementation increases functional scores in patients with osteoarthritis of the knee, especially within three months of injection (Campos, et al.). Viscosupplementation is recommended for patients with a history of lasting benefit from prior injections. The patient has reported benefit with previous viscosupplementation injections to the knees. In this case, the medical evidence supports the requested treatment in this clinical setting. Therefore, a Monovisc injection is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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. Findings:  The physician reviewer found that