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 a plastic surgeon consultation for breast augmentation.  Findings:  The physician reviewer found that The World Professional Association for Transgender Health (WPATH), a worldwide authority on transgender health issues, has stated that medically necessary gender affirming/confirming surgical procedures include chest reconstruction or augmentation as appropriate to each patient, including nipple resizing or placement of breast prostheses, as necessary. The medical procedures attendant to gender affirming/confirming surgeries are not cosmetic or elective or for the mere convenience of the patient. These procedures are reconstructive surgeries. The Transgender Medicine Model NCD Working Group has explained that in transgender woman who undergo hormone therapy, maximal breast development is generally reached within two years. While hormone therapy alone is sufficient to achieve breast size appropriate to age and body habitus in some transgender women, for 40 to 70 percent of transgender women breast reconstruction may be necessary in order for the individual to pass as female and thereby reduce or resolve gender dysphoria. Mammoplasty in transgender women serves primarily a therapeutic purpose and should be considered reconstructive rather than cosmetic. In this case, the patient has been on cross gender hormone therapy and has had other gender confirming surgeries, and her gender dysphoria has not been alleviated by these other treatments. The patients therapist has confirmed that breast augmentation surgery is now required to therapeutically treat the patients gender dysphoria and relieve the patients present distress. Under these circumstances, the requested consultation with a plastic surgeon for breast augmentation is medically necessary to treat the patients medical condition.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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested reimbursement for the radiofrequency ablation. On review of the current medical literature, there are data to support the use of radiofrequency ablation in spine. However, there is a paucity of adequate evidence demonstrating improved patient health outcomes with radiofrequency ablation of the hip. Overall, the studies on radiofrequency ablation of the hip include retrospective, case series, and pilot studies. In addition, this patients records provided for review do not include provider documentation outlining the standard treatment options for pain have been exhausted. Specifically, treatment with behavior therapy has not been attempted, despite much research to support its use in this clinical setting. Moreover, not all antidepressants used for pain have been optimized or tried. Furthermore, the test block was performed with steroid without a pain diary. For these reasons, the radiofrequency ablation was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the radiofrequency ablation was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. One Reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing.  One Reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Factor V Leiden (FVL) Mutation Analysis lab testing. The submitted documentation supports the medical necessity of the requested testing. Factor V Leiden (FVL) is a mutant form of coagulation factor V. Multiple studies have demonstrated that there is an increased risk of venous thromboembolism (VTE) in individuals with the FVL mutation. The risk of VTE can further be increased with aging, homozygosity for the FVL mutation, or coinheritance of another thrombophilia with FVL. The risk of VTE can also be increased with acquired factors such as pregnancy or oral hormonal contraceptives and cancer. Testing in individuals under the age of 45 and/or someone with a family history of blood clots is considered a standard of care. In this case, has a family history of blood clots, and has a recent history of DVT. Under these circumstances, the requested Factor V Leiden (FVL) Mutation Analysis lab testing is medically necessary for treatment of the patients medical condition.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 internal medicine, with subspecialty certification in hematology, 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 parent of the patient has requested reimbursement for residential treatment center services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, treaters score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Per CALOCUS, RTC level of care requires a composite score of at least 23.Regarding the six CALOCUS dimensions, the patient has a low risk of harm; the records do not indicate he was suicidal (score = 2). Regarding functional status, the patient has had some issues with level of functioning due to mental illness and relational issues, but overall showed appropriate daily functioning while in treatment (score = 2). Regarding comorbidities, the patients past medical issues did not appear to adversely impact him during the disputed days of service (score = 2). The patient was noted to have interpersonal conflict with family members due to his running away from home; however, the progress notes document that his relationship and family sessions were productive and not adversarial (score = 2) and the patients parents are involved and supportive (score = 2). With respect to treatment success, the patient had an aggressive outburst during a recent short stay at an RTC. For the dates of service at issue here, however, the patient was participating in therapy programming and did not display any serious or disruptive symptoms (score = 3), participated in therapy and was cooperative with consistent engagement (score = 2) and has parents who work actively and constructively with clinicians (score = 2). For a CALOCUS composite score of 17, the recommended level of care is high-intensity outpatient therapy. Therefore, the RTC services were not medically necessary for this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in child and adolescent psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tonsillectomy surgery. Indications for a tonsillectomy include recurrent throat infection with documentation. Clinicians may recommend a tonsillectomy for recurrent throat infection with a frequency of at least seven episodes in the past year; at least five episodes per year for two years; or at least three episodes per year for three years. There should be documentation in the medical records for each episode of sore throat, and documentation of one or more of the following: temperature greater than 38.3 degrees Celsius, cervical adenopathy, tonsillar exudates, or a positive test for Group A Beta-Hemolytic Streptococcal infections (GABHS). While recurrent infection remains the most common indication for an adult tonsillectomy, there is a growing rate of tonsillectomies performed for upper airway obstruction. In the adult population, a tonsillectomy is the appropriate first line treatment in select patients. Tonsillectomy has been shown to be a very effective treatment regardless of the severity of the obstructive sleep apnea (OSA). In this case, the patient had three episodes of strep throat infection this year and did not undergo a sleep study to document OSA. Although she has enlarged tonsils, she does not meet the criteria for a tonsillectomy for either recurrent infection, or for OSA. Accordingly, the requested tonsillectomy surgery is not medically necessary for this patient.Final Result: The reviewer determined that the requested procedure 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 otolaryngology, with subspecialty certification in plastic surgery within the head and neck, 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

An enrollee has requested reimbursement for dental braces. The submitted documentation does not support the medical necessity of the services at issue. Colleagues have studied the relationship between malocclusion and quality of life in adolescents. Their study concluded that malocclusion and orthodontic treatment do not appear to affect general or oral health quality of life to a measurable degree. This is despite subjective and objective evidence for improved appearance, oral function and health and social well-being. To assess the need for orthodontic treatment, there are many objective tools to quantify the degree of handicap caused by the malocclusion. Orthodontic treatment need indices are used to rank the malocclusion. Colleagues have explained that these indices were devised to minimize the subjectivity associated with the diagnosis, referral and complexity assessment of malocclusion. One widely used tool is the Handicapping Labio-Lingual Deviation (HLD) Index. In this case, the HLD Index score computed by the treating orthodontist did not reach the threshold for severe malocclusion. In addition, the submitted records do not suggest there were issues with speech, swallowing or nutrition; nor is there a defined medical condition that would necessitate treatment. The records state that the patient has a slight open bite on the right side. The records do not demonstrate that this is a significant disability causing an impediment to normal chewing. The records indicate no demonstrated excessive malocclusion, mild crowding and some tooth rotations, and no excessive overjet or overbite. Under these circumstances, the dental braces provided to the patient were not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were 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 dental 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast reduction, including the removal of fat, glandular tissue, and skin. The submitted documentation does not support that the requested services are medically necessary. Breast implants are not an abnormal structure of the body, and excess breast weight from breast implants is not the result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. Breast ptosis is also not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. It is not an abnormal structure of the body. It is a normal structural change that is an accommodative response to gain or loss of body mass, gravity, and physical aging. Under the circumstances of this case, the requested breast reduction, including the removal of fat, glandular tissue and skin, is not medically necessary for treatment of the patients medical condition. Furthermore, the requested services do not constitute medically necessary reconstructive surgery, as the patients medical condition does not involve an abnormal structure of the body that was caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease structures.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for the medication frovatriptan succinate 2.5mg. The submitted documentation supports the medical necessity of the requested medication. Menstrual migraine is defined as migraine without aura that occurs within days -2 and +3 of the menstrual period on at least 2 of 3 consecutive menstrual cycles (where menstruation onset is defined as day 1). Studies have stated that evidence from frovatriptan studies meets the AAN threshold for a Level A recommendation for short-term use to prevent menstrual migraine. Researchers recommend frovatriptan as effective for menstrual headaches. In this case, the patient has tried and failed with sumatriptan and rizatriptan. The patients chronic migraine headaches have improved with zolmitriptan. Zolmitriptan, however, has not been effective for migraine exacerbations during the patients menstrual cycles, as documented in the providers letter dated 11/01/18. Under these circumstances, frovatriptan succinate 2.5mg is medically necessary to treat the 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections for the right knee. The submitted documentation supports the medical necessity of the requested services. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. There is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. A systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Intra-articular hyaluronic acid has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, Orthovisc injections for the right knee are medically necessary to treat the patients medical condition at this time.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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections of both knees. The submitted documentation supports the medical necessity of the requested services. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. There is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. A systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Intra-articular hyaluronic acid has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, Synvisc injections of both knees are medically necessary to treat the patients medical condition at this time.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.