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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for facial feminization surgeries (brow lift, jaw reduction/contouring, lip reduction and rhinoplasty) for treatment of the enrollees gender dysphoria.  Findings:  The physician reviewer found based on the medical documentation provided for this review, a portion of the services at issue is medically necessary and reconstructive in nature. The medical literature supports facial feminization surgery, which may include forehead remodeling, rhinoplasty, thyroid chondroplasty, and voice alteration procedures for treatment of gender dysphoria. This patient has documented gender dysphoria. However, the photographs provided show evidence of a relatively normal forehead without evidence of an abnormal gender appearance.  The brows are in a relatively normal position without significant ptosis or an abnormal gender appearance. The nose and lips are relatively normal, without an abnormal gender appearance. The documentation provided, including a review of the photographs, do not support the medical necessity for the brow lift, lip reduction and rhinoplasty. These findings are relatively gender neutral and should have been considered treatment of relatively normal structures in this patients case. On the other hand, the patient showed evidence of a significantly masculine appearance of the lower face, specifically, the chin and jaw.  The chin and lower face demonstrated a significantly widened masculine appearance for a female. As such, this should have been considered outside the normal structures typical for a female. Therefore, jaw reduction/contouring was medically necessary for treatment of this patients gender dysphoria. However, brow lift, lip reduction and rhinoplasty were not medically necessary. Final Result: The reviewer determined that a portion of the services at issue was medically necessary and was reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested authorization and coverage for scar revision surgery for treatment of the enrollees scars and not reconstructive in nature. Findings:  The physician reviewer found this patient presents with evidence of symptomatic keloids/hypertrophic scars of the breasts, abdomen and umbilicus that is confirmed by review of the photographs and medical records. She has significant pain and tenderness associated with her scars that has failed conservative management with topical creams. The patient has a functional impairment directly related to an abnormal result from surgical intervention. Thus, resection and revision of her scars is medically necessary. In addition, the patients condition constitutes an abnormal structure of the body as she does not have normal scarring. Moreover, the planned surgery would help to improve her functional impairment of pain and approximate a more normal appearance of the scars with a more than a minimal improvement in the patients appearance. All told, the requested scar revision surgery is supported as medically necessary and reconstructive in nature for treatment of this patients keloid scars. Final Result: The reviewer determined that the requested surgery is medically necessary for treatment of the patients medical condition and reconstructive in nature. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50/100 mg for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent 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 limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1b patients should be treated with regimens including Zepatier for 12 weeks. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. All told, Zepatier 50/100 mg for 12 weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ThyGenX testing. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees thyroid nodule.  Findings:  Two physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign. The relatively new development of molecular techniques and the identification of genetic alterations associated with different follicular cell-derived cancers in the thyroid have led to the introduction of several commercially available tests. Among these tests is ThyGenX, which analyzes a panel of deoxyribonucleic acid mutations and ribonucleic translocation fusion markers to assess the risk of malignancy with good negative and positive predictive value. ThyGenX testing may allow patients to avoid unnecessary surgeries. There is sufficient support for the services at issue in this clinical setting.  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 endocrinology, diabetes and metabolism 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 enrollee has requested surgery to repair, remove, or replace a hernia mesh implant for treatment of the enrollee who has a history of chronic pain in the abdomen/stomach area. Findings:  The physician reviewer found that this patient has had extensive tests to determine the cause of his abdominal pain. These tests were negative. In the absence of organic findings for abdominal pain on imaging, chronic pain associated with mesh is therefore a possibility.  Other possibilities include irritable bowel syndrome, given that this patients pain is relieved with bowel movements.  However, the gastroenterology consultation did not definitively advise further treatment for this beyond therapy with the medication Xifaxan.  The studies have shown that it possible to develop chronic pain after an inguinal hernia repair. The incidence of chronic pain in such cases has increased over time with the use of hernia mesh.  Additionally, there is evidence that surgical repair of pain associated with a mesh can be effective.  Therefore, the request for surgery to repair, remove, or replace the hernia mesh implant is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal collagen cross-linking for treatment of the enrollees keratoconus.  Findings:  The physician reviewers found that treatment for the patients condition with collagen cross-linking was medically appropriate.  Based on the patients vision loss and progression, corneal collagen cross-linking was the most appropriate and effective treatment available.  The medical evidence has demonstrated that corneal collagen cross-linking is a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant. Furthermore, corneal collagen cross-linking for corneal ectasias fulfills an unmet need. There is a lack of treatment options available to slow or halt disease progression. Therefore, corneal collagen cross-linking was likely to have been of greater benefit than other available treatment options. Final Result: Two of three reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  Physician reviewers number one, tow, and three are board certified in ophthalmology and 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for tumor treating fields therapy (Optune) for treatment of the enrollees brain cancer (glioblastoma multiforme). Findings:  Three physician reviewers found that there is support in the medical literature for the efficacy of the services at issue in this clinical setting. The standard treatment of glioblastoma in the adjuvant setting is with radiation, temozolomide and alternating electric field stimulation (Optune).  The medical studies have shown that adding tumor treating fields therapy to maintenance temozolomide chemotherapy prolonged progression free and overall survival. As such, the tumor treating fields therapy (Optune) was likely to have been more effective for the treatment of this patients medical condition than the available standard options. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment 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 Lyrica for treatment of the enrollees multiple sclerosis (MS). Findings:  The physician reviewer found that Lyrica has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of post herpetic neuralgia, diabetic neuropathy, fibromyalgia, other neuropathic pains syndromes and epilepsy. It has been extensively utilized for both central and peripheral neuropathic pain, and the medical literature is replete with studies showing its effectiveness. Lyrica is recommended for a variety of neuropathic pain syndromes in various reviews of chronic neuropathic pain. Lyrica has been recommended as a first-line agent in a meta-analysis concerning treatment of chronic neuropathic pain. Given that this patient has reportedly tried treatment with nortriptyline, gabapentin, tramadol, and amitriptyline and the recognized utility of Lyrica for treatment of neuropathic pain, Lyrica is clinically indicated for this patient. Moreover, prior authorization and step therapy policies that restrict the use of Lyrica may lead to a higher utilization of opiates. 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 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 blood test for evaluation of the enrollees autoimmune disorder. Findings:  The physician reviewers found there is sufficient support in the peer reviewed literature for the immune function tests. The patients provider needs the clearest possible picture of what the patients immune parameters are in order to formulate the best possible treatment plan and to have further insight into this patients SRE with respect to the clinical course. Accordingly, the medical literature supports the efficacy of these assays in the evaluation of this patients medical condition. For these reasons, the blood test (immune cell function assay). was likely to have been more efficacious than the available options of evaluating this patient. Final Result: Two of three reviewers determined that the services were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  Physician reviewers number one, two, and three are board certified in allergy and immunology with expertise in pediatric immunology and 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 hydrocodone 7.5-325 mg oral tablet and Breg Polar Care Cube Cold Therapy System for treatment of the enrollees right shoulder rotator cuff tear. Findings:  The physician reviewer found that post-operative continuous flow cryotherapy after shoulder surgery has been shown to be of benefit for seven days. It reduces pain, swelling, inflammation, and the need for narcotics after surgery. Based on this patients medical records and recent medical literature with regard to continuous-flow cryotherapy for shoulder surgery, the requested Breg Polar Care Cube Cold Therapy System is supported as medically necessary for seven days postoperatively. With respect to the request for hydrocodone 7.5-325 mg with acetaminophen, weaning is suggested. Thus, the Breg Polar Care Cube Cold Therapy System for post-operative use for seven days and hydrocodone 7.5-325 mg oral tablet for one month are supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing for evaluation of the enrollee, who has a family history of breast cancer. Findings:  The physician reviewers found this patients mother fulfilled criteria for genetic testing to test for heritable risk for breast cancer. Now, since she is deceased, the patient has incomplete data on which to make decisions regarding her breast cancer risk. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic and gastric cancers. BRCA2 mutations can increase risk for breast, ovarian, gallbladder, bile duct, prostate, pancreatic, and gastric cancers. In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. There are guidelines in place that evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) tumors in families. The most common extracolonic cancer in Lynch syndrome is endometrial cancer followed, in no particular order, by ovarian, gastric, renal, small intestine, pancreas, hepatobiliary, and ureteral. In this patients case, the MyRisk panel was appropriate since the current clinical situation may be caused by several potential cancer-causing genes. Thus, gene testing was likely to have been of greater benefit than other available modalities for evaluating this patient. Final Result: Two of three 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and 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 nusinersen (Spinraza) for treatment of the enrollees spinal muscular atrophy (SMA). Findings:  The physician reviewer found that Spinraza is the first drug approved to treat pediatric and adult patients with spinal muscular atrophy (SMA). Spinraza is an antisense oligonucleotide that is designed to increase the expression of the survival motor neuron protein, which is deficient in patients with SMA. Although this patient has significant motor deficits from his SMA, he is able to perform activities of daily living (ADLs) with difficulties and is still working. Increasing the expression of motor neuron protein in the patients surviving motor neurons may improve or delay the progression of the patients motor deficit. Overall, the patient is still relatively functional and Spinraza may help the patient continue to perform ADLs and work. Thus, the requested Spinraza is supported as medically necessary for treatment of this patients SMA. 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 neuromuscular 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested reimbursement for the Afirma Gene Expression Classifier (GEC) for evaluation of the enrollees thyroid nodule. Findings:  The physician reviewers found in this case, the patients initial biopsy demonstrated FLUS. Thus, additional testing with Afirma GEC was indicated to help determine the need for surgery. Afirma testing is generally considered standard protocol on all FNA samples for thyroid nodules. Moreover, there is sufficient peer-reviewed medical literature to support the utility of the Afirma GEC in this clinical setting. For these reasons, the Afirma GEC provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the testing at issue was 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and 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.