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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for methadone three times per day and Norco for treatment of the enrollees chronic pain due to fibromyalgia and cervical and lumbar radiculopathy. Findings: The physician reviewer has found based on the presented clinical records, the request for methadone and Norco are medically necessary for treatment of the patients medical condition. In this case, the patient presents with chronic nonmalignant pain. Her diagnoses include fibromyalgia and cervical and lumbar radiculopathy. Treatment with opioid medication can be considered as part of the standard of care when treating patients with chronic nonmalignant pain. There is evidence of failed treatments including non-medication management, interventional care, and non-opioid medications. Methadone, a long-acting medication is being prescribed for baseline pain and Norco which is a short-acting combination opioid is being used for intermittent or breakthrough pain. In terms of the dosing, the daily MED being requested is 120 mg per day. Guidelines have identified a threshold ranging from 50 mg to 200 mg per day in terms of the threshold at which increased vigilance should be exercised. In this case, the patients medications are providing a significant improvement in pain and allowing her to continue working based on her assessment in March 2017. Also, there is no evidence of abuse or addiction with consistent urine drug screening and the patient has been managed with these medications on a long-term basis. The patient reports worsening pain and difficulty functioning when her medications were tapered which supports the medical necessity of ongoing use. Another trial of opioid medication tapering should be considered in approximately six months as guidelines support an attempt to taper every six months to assess whether ongoing chronic opioid therapy is medically necessary. For these reasons, the request for methadone 5 mg three times per day TID and Norco 10/325 mg are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medications 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 physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the prostatic urethral lift procedure for treatment of the enrollees benign prostatic hyperplasia (BPH). Findings:  Two reviewers found that the prostatic urethral lift procedure is a minimally invasive approach to treating BPH that lifts or holds the enlarged prostate tissue out of the way so it no longer blocks the urethra. Recent clinical trials including prospective sham controlled randomized studies have shown that the UroLift system is safe and effective in relieving lower urinary tract symptoms due to BPH without significantly compromising sexual function. A recent prospective, randomized, multinational study compared the outcome of prostatic urethral lift to transurethral resection of the prostate and concluded that participants who underwent prostatic urethral lift responded significantly better than those who underwent transurethral resection of the prostate (TURP) as therapy for benign prostatic hyperplasia with regard to important aspects of quality of life. Final Result: Two reviewers determined that the requested procedure is 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: All three of the physician reviewers are board certified in urology 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 Harvoni for 12 weeks for treatment of the enrollee's chronic hepatitis C virusl genotype 1a.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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). Consideration for eight week therapy in patients with baseline viral load of less than six million IU/mL is based on post-hoc analysis of treatment naive patients in the ION-3 trial, resulting in an uncontrolled comparison (Kowdley, et al). The AASLD/IDSA guidelines state that these results are not generalizable and that treatment duration of less than 12 weeks should be done with caution. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laser hair removal for treatment of the enrollees gender dysphoria.Findings:  The physician reviewer found that 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 condition 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, the records noted that hormone therapy has not been effective in improving this patients medical condition. Therefore, laser hair removal is medically necessary for 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 make-up of the patient. As such, the requested facial hair removal can provide substantial 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 and are 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 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 laser hair (facial) removal for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that 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 condition where terminal hair grows in a 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, the records noted that hormone therapy has not been effective in improving this patients medical condition. The patient reported that she is continually being misgendered. Therefore, laser hair (facial) removal is medically necessary for 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 make-up of the patient. As such, the requested facial hair removal can provide substantial improvement in the appearance of terminal hair and create as normal an appearance as possible. Moreover, the requested services are going to improve emotional function for this patient. All told, laser hair (facial) removal is reconstructive in nature. Final Result: The reviewer determined that the requested services are medically necessary and are 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 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 has requested authorization and coverage for total hip arthroplasty for treatment of his hip pain. Findings: The physician reviewer has found in this patients case, evidence based medical guidelines and peer reviewed criteria have been met for the requested services. Evidence based medical guidelines recommend total hip arthroplasty when all reasonable conservative measures have been exhausted and other reasonable surgical options have been seriously considered or implemented. Specific guideline criteria include exercise therapy (supervised physical therapy and/or home rehabilitation exercises) and medications (unless contraindicated, non-steroidal anti-inflammatory drugs or steroid injection). Subjective findings should include limited range of motion, or nighttime joint pain, or no pain relief with conservative care. Objective findings should include patients 50 years and older with a body mass index less than 35. Imaging findings of osteoarthritis on standing x-rays or arthroscopy are required. The American College of Rheumatology recommends total joint arthroplasty for patients with hip osteoarthritis following failed medical therapy. Medical therapy recommendations include exercise, weight loss for overweight patients, medication management, walking aids, and psychosocial interventions. This patient presents with severe and worsening left hip pain. There is imaging evidence of bone-on-bone osteoarthritis, which would warrant an exception to peer reviewed guideline/literature recommendations relative to age. His calculated body mass index is less than 30. He has significant functional difficulty in weight bearing and activities of daily living. There is limited range of motion, and nighttime joint pain. There is imaging evidence of advanced osteoarthritic changes in the left hip, reported as bone-on-bone. He is status post right total hip arthroplasty with good results. Recent conservative treatment had included activity modification, over the counter medications, and home exercise program. Given the severity of the degenerative changes, additional conservative treatment would not typically be supported prior to surgery. Therefore, the request for total hip arthroplasty is medically necessary for treatment of the 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 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: An enrollee has requested reimbursement for hormone implants. Findings:  The physician reviewers found that the Endocrine Society recommends that the diagnosis of hypogonadism be made in men who have both consistent signs and symptoms and low total testosterone levels. Testosterone should be administered to adult males who are hypogonadal, as evidenced by clinical symptoms and signs consistent with androgen deficiency and a subnormal morning serum testosterone concentration on separate occasions. Symptoms suggestive of androgen deficiency include low libido, decreased morning erections, loss of body hair, low bone mineral density (BMD), gynecomastia, and small testes. Fatigue, depression, anemia, reduced muscle strength, and increased fat mass are less specific. After hypogonadism is diagnosed, it is important to determine whether a patient has primary or secondary hypogonadism by measuring the serum luteinizing hormone (LH) and follicle stimulating hormone (FSH). With regard to treatment, there is uncertainty about the risks and benefits of long-term testosterone therapy. Generally no one testosterone preparation is preferred over alternates. In conclusion, there is a lack of data to support the diagnosis, success of therapy, or rationale for changing from intramuscular injections to pellets in this patients case. Thus, the hormone implants provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Results: 2 of 3 reviewers determined that the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is 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: An enrollee has requested authorization and coverage of Subutex 2 mg sublingual (SL) twice daily for treatment of the enrollee who has a history of low back pain. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the requested medication in this clinical setting. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non-palliative setting. However, in the documentation available for review, no objective treatment goals for pain and function were noted for the requested medication. Behavior therapy was not noted as performed despite much research to support its use. Additionally, not all non-opioid medications classes have been optimized or tried.  Also, there are other non pure mu agonist that have long lasting duration that may be available to the patient. There is no documentation of counseling despite research and recommendations to support its use in opioid dependency. It is unclear what the plan is for this patients opioid dependency since the notes state she is taking Tramadol and buprenorphine (Subutex). Moreover, there is no clear objective functional goals for the buprenorphine being requested. Buprenorphine is U.S. Food and Drug administration approved and indicated for opioid dependence. However, the patient states she is taking the medication for pain control. Furthermore, it is unclear from the records why the provider and the patient believe Suboxone should be avoided; Suboxone is sufficient. In addition, while the provider states that there is a desire to be off all opioids, the medical record does not show that this patient has been weaned off Norco and fentanyl, given the request for 99 refills on the buprenorphine sublingual. Finally, despite drug testing being noted in the plan, there are no laboratory data submitted as to the results of those tests. Moreover, multiple minimal requirements for opioid prescribing have not been performed. The need to use buprenorphine alone or alongside another opioid, for an indefinite basis, as the primary medication treatment strategy for pain or opioid dependency has not been established. For all these reasons, the requested coverage for Subutex 2 mg SL, twice daily, 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 anesthesiology with sub-certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  Ab enrollee has requested reimbursement for the Foundation One Heme test. Findings:  Two physician reviewers found that the utility of the Foundation One testing has not been demonstrated in prospective randomized clinical trials for use in this setting. Further, there is a lack of clinical trials comparing the strategy of targeted treatment based on panel results with standard of care. The available literature on clinical utility consists of a small number of uncontrolled studies, and nonrandomized controlled trials that use imperfect comparators. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. Final Result: Two reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers 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 transcranial magnetic stimulation (TMS) treatment for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  Based on the patients PHQ-9 score, it appears that he has moderately severe depression.  The current literature on TMS does not indicate that this treatment needs to follow numerous medication failures. This patient does not appear to have any comorbid substance abuse or personality disorders. Most of the literature supporting TMS considers comorbid disorders to be exclusionary. The evidence-based literature for TMS has grown over the past several years. There is supporting evidence in the literature that numerous medication trials do not often yield higher levels of success. All told, the requested TMS treatment is 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.