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 Prolia injection (CPT code J0897) 60 mg, once every six months for a year.Medical literature supports that the requested medication is medically necessary. authors reviewed the pharmacology and major clinical trials and concluded that denosumab (brand name Prolia) is an efficacious and safe osteoporosis treatment option, with current data up to eight years of continued use showing continued improvement in bone density with sustained fracture risk reduction. They found that safety profiles overall are similar to placebo, with no new safety concerns in extension trials, though a theoretical increased risk of infection exists with receptor activator of nuclear factor-B ligand (RANKL) inhibition. Researchers have stated that although bisphosphonates remain the mainstay of treatment for osteoporosis and metastatic disease in woman with breast cancer, the ABCSG-18 trial showed that patients who started denosumab within 3 months of the start of aromatase inhibitors were the ones deriving more benefit from treatment. They noted that in the D-CARE trial, it was mandatory to start treatment no later than 3 months after surgery, so patients had the ideal time window to receive denosumab.In this case, the patient did not tolerate Zometa for her osteoporosis. She did not have an acute phase reactant situation with body aches lasting a few days, rather, she had body aches lasting a few weeks. Although the literature suggests that the flu-like symptoms and body aches which can occur with Zometa are not a class reaction, the patient experienced extensive, ongoing symptoms. For this reason, she should not have to take oral bisphosphonates prior to trying Prolia. Prolia would be a good option for this patient, who had extensive adverse effects with a bisphosphonate that extended beyond flu-like symptoms. Under these circumstances, the requested Prolia injection (CPT code J0897) 60 mg, once every six months for a year, is medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested medication is medically necessary for the 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 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: An enrollee has requested reimbursement for vitamin D testing.Overt vitamin D deficiency is not common in most developed countries. However, subclinical vitamin D deficiency can occur and is associated with osteoporosis, increased risk of falls and fractures. It is generally not recommended to screen normal healthy adults with no symptoms of deficiency. Screening should be considered for higher risk groups, including patients who are institutionalized, and patients who have kidney disease, osteoporosis or malabsorption bowel disease. After the initial screening and diagnosis of vitamin D deficiency, follow up labs should be done to determine normalization of levels after initiation of vitamin D supplementation. Once levels are achieved, no further testing is needed. In this case, the patient reported a previous history of vitamin D deficiency and started supplementation. It was the responsibility of the patients new primary care physician to determine that the patients vitamin D levels were normalized with his supplementation. The vitamin D testing at issue found that the patients vitamin D level was mildly elevated, and he was advised to discontinue the supplement. Under these circumstances, the vitamin D testing at issue was medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.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 enrollees parent is requesting authorization and coverage for a consult regarding a bilateral mastectomy and male chest reconstruction, and for a bilateral mastectomy and/or male chest reconstruction. The enrollee is a male who was treated by a psychiatrist for gender dysphoria, anxiety, and panic disorder. His secondary sex characteristics cause him to feel anxious and depressed. He binds his chest tightly every day. He has been taking oral contraceptives and progesterone. His current therapist has recommended bilateral mastectomy with male chest reconstruction. Records show the enrollee was previously evaluated by social work and found capable of making the decision to transition. This enrollee has many mental health issues; related to the gender dysphoria or not, they apparently first presented three years prior and the concern is whether these issues can be resolved while still an adolescent. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 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 intensive group therapy services three times a week specifically for transitional adults (18-24 years old).The submitted documentation supports that the requested services are medically necessary. Transitional age youth are young people moving from adolescence to young adulthood (ages 18-24). They have stressors that are unique to this age group including: moving away from family, becoming independent, developing ones identity, and learning to handle more complex relationships. For this age group, handling these tasks while adjusting to the start of college can be challenging. Research has shown that without a structured transition process (such as a psychotherapy group for ages 18-24), youth and young adults are more likely to have problems with medical complications, limitations in health and wellbeing, difficulties with treatment and medication adherence, discontinuity of care, and preventable emergency department and hospital use. In this case, the patient was struggling to adjust to college life and was having severe depressive episodes, dissociation, and suicidal ideation. At this time, the patient has severe depression with a recent history of a suicide attempt of high lethality. The patient poses a high risk of decompensation should she be treated in a program that is not specialized to the behavioral needs of her age group. Under these circumstances, the requested intensive group therapy services three times a week specifically for transitional adults (18-24 years old) are medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested services are medically necessary for the 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

ture of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for postural restoration services. The possible etiologies of diaphragmatic paralysis include trauma and iatrogenic interventions. Absent clear trauma or iatrogenic etiologies, cases are deemed to be due to an idiopathic neuropathy. Treatment can include surgery such as diaphragmatic plication and implantation of diaphragmatic pacemakers. Limited studies have also suggested a possible role for phrenic nerve reconstruction for treatment of diaphragmatic paralysis. Overall, there is a lack of data demonstrating improved patient health outcomes, including pulmonary function, with the use of postural restoration services for diaphragmatic paralysis. All told, the requested postural restoration services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested postural restoration services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are 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: Physician reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation 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: The patient has been diagnosed with adenocarcinoma of the right lung. The provider noted a positron emission tomography (PET) showed a hypermetabolic peri-carinal lymph node. Additionally, a right paratracheal node had increased in size. The provider also noted that an endobronchial ultrasound (EBUS) revealed metastatic adenocarcinoma. The provider noted that the patient was treated with carboplatin and paclitaxel with radiation. The provider noted that the patients tumor was epidermal growth factor receptor (EGFR) exon 19 mutation positive. The provider noted that imaging showed invasive pulmonary adenocarcinoma and metastatic adenocarcinoma in three of seven lymph nodes. The provider noted that the patient was status post right upper lobe and right middle lobe lobectomy and lymph node dissection in. The patient was also treated with cisplatin/pemetrexed and carboplatin/taxol with radiation. The patient has requested authorization and coverage for Imfinzi (durvalumab). The Health Plan denied the request and reported that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Imfinzi (durvalumab) is medically necessary for the treatment of the patients medical condition. The National Comprehensive Cancer Network (NCCN) guidelines note, Durvalumab is not recommended for patients following definitive surgical resection. The NCCN guidelines recommend durvalumab as consolidation immunotherapy (regardless of PD-L1 status) for eligible patients (PS 0-1) with unresectable stage III non-small cell lung cancer (NSCLC) who have not progressed after treatment with two or more cycles of definitive concurrent platinum-based chemoradiation based on this trial and U.S. Food and Drug Administration (FDA) approval. This patient initially had a stage IIB NSCLC and completed treatment. Recurrent disease was documented. The medical evidence does not support the requested medication in this clinical setting. Therefore, Imfinzi (durvalumab) 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 with sub-specialty certification in medical oncology and 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with coronary artery disease (CAD). The patient reported occasional chest tightness and a vague aching sensation that occurred with exercise and rest. The patient was treated with a two-vessel coronary artery bypass graft (CABG). The provider noted nuclear stress testing and a stress echocardiogram were negative for ischemia. The patient has requested reimbursement for coronary computerized tomography angiography that was provided. The Health Plan denied the request and reported that the services at issue were not medically necessary for the evaluation of this patient. At issue in this case is whether coronary computerized tomography angiography was medically necessary for the evaluation of the patients medical condition. Barbero and colleagues reported, A non-invasive approach to define grafts patency and stenosis in the follow-up of CABG patients may be an interesting alternative to coronary angiography. 64-slice-coronary computed tomography is nowadays a diffused non-invasive method that permits an accurate evaluation of coronary stenosis, due to a high temporal and spatial resolution. In this case, the patient has known coronary artery disease and prior bypass surgery. The persistence of his chest symptoms made further investigation reasonable. In the presence of ongoing symptoms and negative non-invasive studies, the only other option is invasive coronary angiography to assess the coronary anatomy and bypass grafts. The medical evidence supports the service at issue in this clinical setting. Therefore, coronary computerized tomography angiography that was provided on 10/19/18 was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service was 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 cardiovascular 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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with right knee osteoarthritis. The patient reported right knee pain associated with clicking. The pain was noted to be exacerbated by sitting and climbing stairs. Physical examination findings included right knee patellofemoral and lateral joint line tenderness. The patient has previously been treated with right knee arthroscopic surgery, physical therapy, and nonsteroidal anti-inflammatory drugs. The provider noted an x-ray revealed degenerative changes in the patellofemoral and lateral compartments. The patient has requested authorization and coverage for Orthovisc injections. The Health Plan denied the request and reported that the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Orthovisc injections are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Orthovisc injections 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for panniculectomy (CPT code 15830) and abdominoplasty (CPT code 15847). According to the American Society of Plastic Surgeons (ASPS), a panniculectomy involves the removal of hanging excess skin and fat in a transverse or vertical wedge but does not include muscle plication, neoumbilicoplasty or flap elevation. When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature. This patients records document that the panniculus hangs below the level of the pubis. The patient complains of a recurrent rash underneath her abdominal pannus and reports that she has used two antifungal medications in the past. However, there is no report that the patient has failed adequate and supervised medical treatment of the rash. The patient does not have a functional problem with the rash that has been demonstrated to be resistant to appropriate medical treatment. Based on the evidence-based literature, the requested panniculectomy (CPT code 15830) is not medically necessary for treatment of this patient. According to the ASPS, abdominoplasty, typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplasty. When indicated, the ASPS specified that CPT 15847 for abdominoplasty describes a cosmetic procedure. Thus, the requested abdominoplasty (CPT code 15847) is not medically necessary for treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this patients case, an abdominal pannus is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumor or disease. The patients abdominal pannus is a normal structural change that is an accommodative response to gain or loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for one to two hours per week of speech therapy services. The records indicate that this patients autism spectrum disorder (ASD) has substantial behavioral roadblocks including inattention and restrictive behaviors, which have prevented his successful participation in speech and language therapy. Syndromes such as Smith-Magenis can be characterized by oppositional and aggressive behaviors that may prove challenging for conventional approaches to speech and language therapy. However, introduction of peer-mediated language interventions can benefit young patients with ASD. Further, adequate neuropsychiatric evaluation of this patient may yield successful and constructive changes to help mitigate oppositional behaviors that may be serving as roadblocks to successful speech and language therapy. Given these findings, two hours per week of speech therapy services are medically necessary for 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 neurology with special qualification in child 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.