Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  A 56-year-old female enrollee has requested reimbursement for advanced lipoprotein testing (CPT code 83695) that was provided for treatment of hypercholesterolemia. Findings:  The physician reviewer found that there are some researchers advocating the use of the advanced lipoprotein analysis, the American College of Cardiology (ACC) guidelines do not support the use of advanced lipid testing. Rather, these guidelines recommend the use of standard risk factors and standard lipid profile testing to make decisions about lipid management. The guidelines have moved away from specific target values and emphasize the use of the pooled risk score analysis for decisions regarding statin therapy. Medical evidence does not support the superior efficacy of the services at issue. The patient has severe hyperlipidemia, but no other clinical risk factors for cardiovascular disease. She was referred for advanced lipoprotein testing to further stratify her cardiovascular disease risk and plans for possible therapy. In this clinical instance, her elevated low-density lipoprotein (LDL) level was an indication to start lipid-lowering therapy. Therefore, advanced lipoprotein testing provided was not likely to have been superior over other methods of evaluating this patient. Final Result: All three reviewers have determined that the advanced lipoprotein testing provided was not likely to have been more effective than other methods of evaluating this patient. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease, and 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 Nutropin AQ Nuspin Pen Injector. Findings  The physician reviewer found the submitted documentation supports that the requested medication is medically necessary. According to published guidelines, a trial of growth hormone (GH) therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations (SDs) below the mean for the age or more than two (SDs) below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two SDs below the mean for age; (4) low serum insulin like growth factor-1 (IGF-1) and/or insulin like growth factor binding protein-3 (IGFBP-3); and/or (5) other clinical features suggestive of GH deficiency. This patient meets above criteria. Final Result: The reviewer found 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 pediatrics with subspecialty certification in pediatric 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 29-year-old enrollee has requested facial laser hair removal. Findings:  The physician reviewer found that the patient has a history of gender dysphoria and has been treated with cross-gender hormone therapy since 2010. The patient reported that the facial hair limits their ability to be perceived as female and negates their gender identity. The patients symptoms of gender dysphoria are reportedly exacerbated when they were mis-gendered due to the presence of facial hair. The patients mental health evaluation documents exacerbation of gender dysphoria symptoms due to the presence of facial hair. Guidelines for the medical necessity of facial feminization surgery (FFS) exist in two reviews from World Professional Association for Transgender Health (WPATH) and the Transgender Law Center. On the classification of laser hair removal as medically necessary, the WPATH states that, in addition to hormonal balancing, medically necessary gender affirming/confirming surgical proceduresinclude  as necessary; facial hair removal, certain facial plastic reconstruction, voice therapy and/or surgery, and gender affirming counseling or psychotherapeutic treatment, as appropriate to the patient. Kalra and colleagues reported that on surgeries or procedures that may be necessary to resolve gender dysphoria and allow transgender women to navigate the world as women include facial and body hair removal. The authors noted that these procedures serve a primarily reconstructive purpose by allowing transgender women whose overall physical appearance otherwise prevents them from being perceived as female. Based on this patients documented history of gender dysphoria, the requested facial laser hair removal is supported as medically necessary. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that the patient has a history of bariatric surgery and peptic ulcer disease.  Per the visit note, she was having symptoms daily with abdominal pain, with no relieving factors. An endoscopy showed a large post-gastrojejunal ulcer measuring approximately 3 cm, which was also noted on a previous endoscopy. Per the pathology report, biopsies showed ulceration, and no Helicobacter pylori was found. Although she was not taking her proton pump inhibitors regularly at the time of the first endoscopy, she was taking omeprazole 40mg twice daily for several months prior to the second endoscopy, and the ulcer persisted. A visit note states that a change from omeprazole 40mg twice daily to Dexilant has improved the patients pain for the first time. The patient has requested authorization and coverage for Dexilant 60mg daily.  The Health Plan has denied the request as not medically necessary for treatment of the patients peptic ulcer disease based on clinical policy, as the patient has not tried two alternative step therapies, including pantoprazole (Protonix) and lansoprazole (Prevacid). At issue in this case is whether the requested medication Dexilant 60mg is medically necessary for treatment of this patients medical condition.Proton pump inhibitor (PPI) therapy is effective for the treatment of gastrojejunal ulcer disease. This patient has failed a high dose of omeprazole, with no ulcer healing after months of use, and then experienced better control of her symptoms with Dexilant. Comparison of multiple PPIs, including the one attempted (omeprazole) and others (pantoprazole, lansoprazole, rabeprazole, esomeprazole), has found no difference in control and healing of gastroesophageal reflux disease (GERD) between them, but has demonstrated superiority of Dexilant to esomeprazole. Dexilant, unlike all other PPIs, is released in an extended fashion. This delivery system results in an extended plasma concentration and a higher mean 24-hour intragastric pH than other proton pump inhibitors. Dexilant is more effective to treat symptoms than alternatives such as esomeprazole. The dose used is appropriate. In this case, the ulcer did not heal, despite treatment for several months with high-dose omeprazole. PPI options besides Dexilant are likely to be similar to omeprazole. For these reasons, Dexilant 60mg is medically necessary for the 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 a 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

Findings:  The physician reviewer found that the enrollee requested authorization and coverage for a Synvisc-One/Hyaluronan Injection. The Health Plan has denied this request indicating that the requested injection is not medically necessary for treatment of the patients right knee primary osteoarthritis. The submitted documentation supports the medical necessity of the requested Synvisc-One/Hyaluronan Injection. Current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. As researchers noted, 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 percent, and suggests that there may be a delay in the need for total knee replacement of around 2 years. Another research performed 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 an 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 service in this clinical setting. Therefore, the requested Synvisc-One/Hyaluronan Injection is medically necessary to treat the patients medical condition at this time.Final Result: The reviewer determined that the requested Synvisc-One/Hyaluronan Injection 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 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: A female patient has requested authorization and coverage for acupuncture. The Health Plan has denied the request, indicating this treatment is experimental or investigational for the enrollees medical condition.At issue is whether acupuncture is likely to be more beneficial for treatment of the patients condition than any available standard therapy. Acupuncture is not a common therapy for the management of trochanteric bursitis. While medical literature indicates that needling is not inferior to cortisone injections in the treatment of GTPS, the literature does not demonstrate a clinical difference or advantage to needling in the treatment of this condition. In this context, it is unlikely that acupuncture would result in a more beneficial outcome for the patient. Therefore, acupuncture is not likely to be more beneficial than any standard therapy to treat the patients medical condition.Final Result: All three reviewers have determined the requested acupuncture services are not likely to be more beneficial than any available standard therapy to treat the patients medical condition. The Health Plans denial for the acupuncture services should be upheld.Credentials/Qualifications:  Reviewer #1 is a is board certified licensed M.D., board certified in oriental medicine, reviewer #2 and #3 are both a licensed D.C., L.Ac., board certified in chiropractic care and oriental medicine and are 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: Upheld Decision of Health Plan

Findings:  The physician reviewer found that this patient has a medical history of type two diabetes, hyperlipidemia and onychomycosis. The patient presented as a new patient with complaints of onychomycosis. She has been treated with topical Jublia in the past with noted improvement to her toenails. The physical examination revealed onychomycosis on toes one through five on bilateral feet, ingrown nail to the left great toe/medial border as well as dry flaky skin with scaling and itching to bilateral feet. The provider reported the patients toenails were debrided at this visit, and a prescription was dispensed for Jublia. At issue in this case is whether the requested medication Jublia, is medically necessary for treatment of the patients medical condition. The British Association of Dermatologists guidelines for the management of onychomycosis advise that problems associated with onychomycosis include discomfort, difficulty in wearing footwear, difficulty walking, and lowered self-esteem. The guidelines also advise that approximately half of all patients with onychomycosis experience pain or discomfort with about 30% of the patient population have difficulty in wearing footwear. In this case, it is well-established that this patient has onychomycosis toenails. The patient has advised in the medical record that she is unable to take oral medications for onychomycosis due to the possibility of liver side effects. However, there is no documentation that this patient has attempted other topical medications for her condition. Furthermore, there is no documentation that this patient complains of pain from onychomycosis. There is no documentation of palpable pain to the toenails and toenail area during the physical examination or that the onychomycosis causes pain with ambulation or wearing footwear. Therefore, Jublia is not medically necessary for the treatment of this patient.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 podiatry 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 a medical history significant for cervical radiculopathy. The patient reported neck pain. The provider reported an abnormal electromyography (EMG) consistent with radiculopathy on the right C4-6. A magnetic resonance imaging (MRI) study revealed cervical foraminal narrowing at C3-4 and C4-5. The patient has been treated with non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants and states that she has failed medications and physical therapy. The provider reported there was decreased range of motion in the neck on physical examination. The provider reported the patient has radicular signs in the lumbar spine due to cervical degenerative disc disease. The patient complained of 7/10 pain with decreased right upper arm strength noted to be 4/5. The provider recommended an epidural steroid injection and to continue with her home exercise program. At issue in this case is whether the requested cervical interlaminar epidural injection is medically necessary for treatment of the patients medical condition. Patients with radiculopathy typically present with neck pain, arm pain or both. Treatment options for radiculopathy include conservative management and non-operative modalities such as physical therapy and steroid injections as well as operative interventions. In this case, two providers report the patient participated in physical therapy and she is currently doing a home exercise program. The patient has also failed oral medications. Literature supports that a home exercise program after physical therapy independent of an epidural can give a patient lasting results. However, this patient has recent physical examination findings and imaging supporting a diagnosis of cervical radiculopathy, for which an epidural steroid injection is indicated. Moreover, the patients condition has not substantially improved with physical therapy and a home exercise program. Therefore, the requested cervical interlaminar epidural injection is 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 anesthesiology with sub-specialties in pain medicine and hospice and palliative 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: A patient has requested authorization and coverage for Methadone HCL tablets. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients medical condition. The submitted documentation does not support the medical necessity of the requested medication. In this case, the patient reports taking Methadone 3 times daily for pain and has been taking this medication for over 5 years. There is no evidence in the medical records provided of prior attempts at long acting opioids, and there is no evidence of a signed opioid contract or evidence of random urine toxicology for compliance. Furthermore, there is no documentation of percent relief, duration of relief, or improvement in function with the use of this agent. Under these circumstances, the requested medication, Methadone HCL tablets, is not medically necessary for treatment of 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 anesthesiology, with subspecialty 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia services provided during a colonoscopy. The Health Plan has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. Findings:  The physician reviewer found that according to the American Society of Anesthesiologists (ASA) guidelines, monitored anesthesia care is warranted in prolonged or painful procedures such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that monitored anesthesia care may be necessary for patients with a history of moderate sedation for the procedure or psychological impediments to cooperation. The provided records do not support these criteria.  The records do not document difficulty with intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications. According to the most recent guidelines from the American Society for Gastrointestinal Endoscopy, consciousness during endoscopic procedures is acceptable and is the goal during most procedures. Monitored anesthesia care is recommended for prolonged procedures requiring deep sedation, previously anticipated intolerance to standard sedatives, ASA class IV or V, or risk for airway obstruction due to anatomic variants. The current guidelines do not support the use of monitored anesthesia during colonoscopy in this case. Therefore, anesthesia services provided during a colonoscopy were not medically necessary. Final Result: The reviewer determined that the requested services 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 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.