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

The enrollee is requesting authorization and coverage for an open magnetic resonance imaging (MRI) scan. The enrollee has a history of ongoing left-sided headaches. The progress note indicates the enrollees pain has been present for four to five months. He complains of mild nausea during severe episodes. Neurology determined the enrollees previous brain magnetic resonance imaging scan from the previous year was negative and prescribed another magnetic resonance imaging scan. The order was for an open magnetic resonance imaging scan, per enrollee request. The enrollee indicates his symptoms have been worsening, with his head hurting every day. However, he cannot participate in a closed magnetic resonance imaging scan due to his anxiety. The last time a scan was attempted, he tried to climb out of it.  Review of the record indicates the enrollees pain is light, dull, aching and constant; with intermittent sharp pain. The enrollee indicated in a telephone conversation that an open magnetic resonance imaging scan was needed due to claustrophobia. According to the medical literature, a magnetic resonance imaging scan of the brain is indicated for enrollees who have headaches with associated neurological findings, or a suspected brain structure abnormality.  The record indicates the enrollee has a two-year history of left-sided headaches and underwent a magnetic resonance imaging scan of the brain the previous year.  However, there is insufficient evidence in the record of the neurology consultation notes and results of the previous magnetic resonance imaging scan. There is no evidence of any neurological deficits on examination or suspected brain structural abnormality that supports the necessity for open magnetic resonance imaging scan at this time.  The clinical records do not support a diagnosis of claustrophobia.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for testosterone gel, 1%. The enrollee has a medical history of solar urticaria, hidradenitis suppurativa, and obesity. Blood work showed a low total testosterone level below the normal range of 250 to 827. His provider reviewed the laboratory results and diagnosed the enrollee with testicular hypofunction, secondary to obesity. Weight loss for fat reduction and muscle building was discussed. AndroGel was prescribed. The enrollee indicates one of the side effects of low testosterone is its affects on the brain, which can lead to anxiety or depression. He reports he now feels depressed, upset and angry. Testosterone gel, 1%, is an androgen indicated for replacement therapy in adult males for conditions associated with a deficiency or absence of endogenous testosterone. Professional society practice guidelines indicate testosterone should be administered only to an adult male who is hypogonadal, as evidenced by clinical symptoms consistent with androgen deficiency, and a subnormal morning serum testosterone concentration documented on three separate occasions. Symptoms of androgen deficiency include low libido, decreased morning erections, loss of body hair, low bone mineral density, gynecomastia, and small testes. The beneficial effects of testosterone in these men are clear, and they should be treated with testosterone to raise their serum testosterone concentrations to normal. Symptoms of fatigue, depression, anemia, reduced muscle strength, and increased fat mass are less specific. The record does not have sufficient clinical/laboratory criteria to define hypogonadism, such as two separate sub-normal serum testosterone levels, drawn in the early morning, on two separate occasions at least two weeks apart. An abnormal serum testosterone value was not confirmed with a second morning testosterone measurement, along with luteinizing hormone and follicle-stimulating hormone to help determine if the has testicular hypogonadism or hypothalamic-pituitary hypogonadism.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in reproductive endocrinology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for residential treatment center (RTC) level of care. The enrollee has a history of substance abuse, borderline personality disorder, eating disorder, depression, suicidal ideation, and suicide attempts. She has a long history of outpatient treatment and 12-step programs. She was hospitalized after presenting with suicidal ideation and a plan to harm herself. She transferred to an intensive outpatient program, but program staff determined she required a higher level of care. She entered the residential treatment center level of care. During her admission evaluation, she reported her substance abuse had escalated to daily use of cocaine, marijuana, and alcohol. She reported work stress and was concerned about losing her job. Her diagnoses on admission were major depressive disorder (recurrent, severe), cocaine and cannabis use disorders (moderate-severe), and borderline personality disorder. The enrollee received individual and group therapy as well as psychopharmacology management. She participated in treatment and was compliant with medications. She remained very anxious, with dysphoric mood and restricted affect. Therapy sessions included coping skills and tools for increased confidence in asking for help. Two days before discharge, she denied suicidal or homicidal ideation and any thoughts of self-harm, but believed she needed more time before transitioning to an intensive outpatient program. She discharged to a partial hospitalization program. The enrollee drinks alcohol daily and denies a history of alcohol withdrawal seizures or delirium tremens. While at the residential treatment center, she was participating in treatment and her medications were adjusted. She had passive suicidal ideation while in the residential treatment center, but denied suicidal ideation at the time of discharge. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. The enrollees composite LOCUS score correlates with medically monitored non-residential services. Medical evidence does not support the service at issue in this clinical setting.Final Result: The reviewer determined that the requested service was not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for a tracheal shave and subsequent post op visits to treat gender dysphoria. The patient is a male-to-female woman. She began her transition at age 17 and started hormone therapy nine years ago. The patient was referred to a voice and swallowing center for vocal cord evaluation. She does not have complaints about her voice but feels her gender is misidentified because of her Adams apple. Her voice and laryngeal evaluation were consistent with gender dysphoria. A rigid video stroboscopy noted vocal fold motion was normal. There was mild mid-vocal fold fullness bilaterally; however, she had no associated dysphonia. The evaluating otolaryngologist has requested authorization for tracheal shave surgery. The patient has expressed a persistent desire for tracheal shave to alleviate her gender dysphoria. Her symptoms have manifested as anxiety, depression, agoraphobia, and overall distress. The patient has met with her medical provider and mental health provider for clearance to pursue gender-affirming surgery. Both providers agree that tracheal shave is medically necessary to treat her gender dysphoria. The patients male-appearing Adams apple severely limits her ability to be perceived as female and negates her female gender identity. Seeing reflections of herself in the mirror is a distressing reminder that her body is not yet aligned with her identity. Because the Adams apple is one of the most visible indicators society uses to identify a person as female or male, tracheal shave surgery is necessary for the patient to survive and thrive in this world as a woman.  The health plan has denied authorization and coverage for vocal cord surgery and speech therapy. The medical literature indicates transfeminine individuals who had completed procedures including tracheal shave or Adam's apple removal reported lower social anxiety than those planning to undergo the intervention. Body-gender congruence and body image satisfaction were higher, while depression and anxiety were lower, among individuals with more extensive gender confirmation treatments compared to those who received less treatment or no treatment. This treatment is part of the patients overall reconstructive plan for her gender dysphoria.                                                         Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for a globin blood test. The U.S. Preventive Services Task Force (USPSTF) guidelines for colorectal cancer screening recommend colonoscopy for colorectal cancer screening, or recommend stool fecal occult blood testing annually, but do not recommend a combination of these tests. Guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) caution that there is an increase in the risk of harm from excessive screening. For patients with a family history of colorectal cancer in a first-degree relative with early-onset colorectal cancer or multiple first-degree relatives with the disease, the guidelines recommend screening more frequently starting at a younger age. However, this type of family history of colorectal cancer is not documented in this case. For patients who have had a tubular adenoma in the past, the most recent applicable guideline is the U.S. Multi-Society Task Force (USMSTF), which recommends colonoscopy for surveillance. The guidelines note that patients should not have interval fecal blood testing if colonoscopy is planned and the guidelines do not support interval fecal testing within the first five years after colonoscopy. The available data reports a high likelihood of false-positive test results, which results in unnecessary early colonoscopies. All told, the requested globin blood test is not supported as medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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 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: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for Epogen solution 20,000 unit/mL.The current medical evidence does not support the requested medication in this clinical setting. Most experts administer Epogen for a hemoglobin of less than 10. In controlled trials, patients experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered erythropoiesis-stimulating agents (ESA) to target a hemoglobin level of greater than 11 g/dL. No trial has identified a hemoglobin target level, ESA dose, or dosing strategy that does not increase these risks. The 2012 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines state that the potential benefits of reducing blood transfusions and anemia-related symptoms should be balanced against the harm in individual patients (such as stroke, vascular access loss, and hypertension). In this case, the patient's hemoglobin has improved to 11.3, which exceeds 11 g/dL, the level above which patients were found to experience greater risks for death, serious adverse cardiovascular reactions, and stroke in controlled trials. Under these circumstances, Epogen solution 20,000 unit/mL is not medically necessary to treat 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 internal medicine, with subspecialty certifications in hematology and medical oncology, 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 combination therapy of Opdivo (nivolumab) plus Yervoy (ipilimumab).Medical literature does not support that the requested combination therapy is medically necessary. The combination of Opdivo (nivolumab) and Yervoy (ipilimumab) does not have available studies to support its use at this time. The recent article in the New England Journal of Medicine on Opdivo (nivolumab) and Yervoy (ipilimumab) involved first line treatment, which is the initial treatment of a given type and stage of cancer. In this case, however, the patient has recurred one year after the completion of first line treatment. There is not enough data in the literature at this time to support the use of combination therapy with Opdivo (nivolumab) and Yervoy (ipilimumab) following first line treatment. Under these circumstances, combination therapy of Opdivo (nivolumab) and Yervoy (ipilimumab) is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested combination therapy of medications 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 subspecialty certification in medical oncology, 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 magnetic resonance cholangiopancreatography (CPT code 74181) of the abdomen.Idiopathic acute pancreatitis is acute pancreatitis in which workup has not revealed a cause. A variety of causes, including anatomic defects, biliary disease, and autoimmune disease are possible In patients with idiopathic acute pancreatitis, magnetic resonance cholangiopancreatography (MRCP) can lead to a diagnosis when other testing has not done so, and can find causes not apparent even on endoscopic ultrasound, which entails procedural risk and requires undergoing sedation  One study showed that when MRCP is used in combination with endoscopic ultrasound, the rate of idiopathic acute pancreatitis is reduced by 66%  A systematic review and meta-analysis comparing MRCP with endoscopic ultrasound concluded that endoscopic ultrasound and MRCP should both be used in the diagnostic work-up of idiopathic acute pancreatitis as complementary techniques, and that MRCP was superior to endoscopic ultrasound in diagnosing anatomic alterations in the biliopancreatic system (such as pancreatic divisum) which can cause acute pancreatitis. In this case, the patient has been diagnosed with idiopathic acute pancreatitis, and other testing and evaluation, including ultrasound of the abdomen, has not revealed a cause. Under these circumstances, the requested magnetic resonance cholangiopancreatography (CPT code 74181) of the abdomen is medically necessary to treat 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 internal medicine, with subspecialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oxandrolone 10 mg tablets.The submitted documentation does not support that the requested medication is medically necessary. Polsky and colleagues note that patients should be treated for HIV-associated wasting only if they meet the criteria for wasting syndrome. They also note that there are several other steps that should be taken that would include management of depression, control of viral load, and treatment of diarrhea and any infectious process. In this case, the submitted documentation does not include documentation of any basis for finding that the patient has wasting syndrome. Furthermore, progress notes reflect that the patient has not lost weight, that his weight has been steady, and that he has a BMI in the normal to overweight range. Under these circumstances, oxandrolone 10 mg tablets are not medically necessary to treat 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 internal medicine, with subspecialty certification in infectious 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollees parent has requested authorization and coverage for services in a social skills group for autism spectrum disorder. The enrollee began receiving relationship development intervention services, engagement in a social skills group, occupational therapy, and speech therapy services.  During the initial psychiatric evaluation, the enrollee demonstrated significant developmental concerns; including stereotyped and repetitive use of language, idiosyncratic language, inflexible adherence to specific, non-functional routines or rituals, overreaction when given direction, and hypersensitivity to noise, textures, smells, and taste. He demonstrates delayed social communication skills, which impact his ability to explain how he feels, describe recent experiences, and engage in meaningful conversations without the communication breakdowns caused by difficulties with clarification and expansion of ideas. The enrollee previously received therapy services and received 1.5 hours per week of behavior-based social skills services and 54 hours of parent consultation over a six-month period. He met his speech goals at this provider and was within the average range when compared to his peers. Due to the enrollees age, he may no longer benefit from intensive traditional applied behavioral analysis, evidencing a plateau in the presentation of his progress. Therefore, it appears appropriate to modify the enrollees treatment regimen to community-based treatment services to assist him in maintaining his skills and generalizing them to the community. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical reviewer is a Licensed Marriage Family  Therapist (LMFT), is a Doctor of Psychology, 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 similar medical condition.