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

Standard Review A transgender female enrollee has requested authorization and coverage for facial feminization surgeries (craniofacial coronal reconstruction with hydroxyapatite (HA) cement, osteoplasty of facial bone reduction of mandibular angles, rhinoplasty major, neck liposuction, upper lip shortening and lowering of the hairline). The Health Plan has denied this request indicating that the requested services are not medically necessary and are not reconstructive in nature for the treatment of the enrollees gender dysphoria. 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. Nature of Statutory Criteria/Case Summary: Based on the entirety of the medical documentation provided for this review, the requested procedures are not medically necessary. The patient is well-documented to have gender dysphoria. Thus, her external anatomy should be more consistent with a female than a male. The patient is noted to have undergone gender reassignment surgery and has been on hormonal therapy for over 20 years. However, in the records provided, there is a lack of documentation that the patient presents with masculine facial features that require surgical treatment. A detailed examination is lacking in the medical records provided for review. In addition, the photographs do not show evidence of a clearly masculine appearance of the brows, forehead, neck, lip and facial bones. Instead, the photographs are more consistent with a female appearance with signs of facial aging.  These findings are gender neutral and not atypical for a female appearance. As such, the documentation provided does not establish the medical necessity of the requested services for treatment of this patient. Therefore, facial feminization surgeries (craniofacial coronal reconstruction with HA cement, osteoplasty of facial bone reduction of mandibular angles, rhinoplasty major, neck liposuction, upper lip shortening and lowering of the hairline) are not medically necessary for the treatment of this patients gender dysphoria.With regard to whether the requested services are considered reconstructive in nature, the submitted documentation does not demonstrate that the patients condition constitutes an abnormal body structure. As stated and reasoned above, the requested facial feminization surgeries are more consistent with aesthetic improvement, addressing appearance concerns and not specific to gender related abnormalities. Thus, this patients facial presentation does not constitute an abnormal body structure. Therefore, the requested services are not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary and are not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast implant removal provided for treatment of an emergency medical condition. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The breast implant removal provided on 2/5/16 was not necessary for treatment of an emergency medical condition. Implant removal may be considered an emergency surgery in cases of documented infection or implant exposure. However, in this case, there is no mention of any concern for possible infection, severe pain that cannot be controlled with oral medication, or other medical condition that would warrant emergency surgery. In the clinical setting of ruptured silicone implants, implant removal and capsulectomies is medically indicated, however, this is not an emergency medical condition. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for distal tibial allograft (fresh) procedure. Findings:  Three physician reviewers found that according to a study of consecutive patients with a minimum 15% anterior glenoid bone loss, patients had recurrent anterior shoulder instability which was treated with fresh distal tibia allograft glenoid reconstruction. Twenty-seven patients were followed up to 45 months. The healing rate was 89% and there were no cases of recurrent instability. The authors concluded that the use of distal tibia allograft reconstruction for recurrent anterior shoulder instability results in a clinically stable joint with excellent clinical outcomes and minimal graft resorption. The study assessed the clinical and radiological outcomes after osteochondral allograft reconstruction for glenoid bone loss. The level IV data suggests that allograft reconstruction for glenoid loss provides excellent clinical outcomes, no rates of recurrent instability, and high osseous incorporation rates with no evidence of graft resorption. In light of the foregoing, the requested procedure of distal tibia allograft reconstruction of the glenoid for recurrent anterior shoulder instability is medically appropriate and likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2 of 3 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 physician reviewers are board certified in orthopedic surgery 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment. Findings:  The physician reviewer found that, in this clinical setting, the services at issue were not and are not medically necessary for the treatment of the patient. There was no evidence of a post-acute withdrawal stated, nor was there any evidence of suicidality, homicidality, or threat to self or others. There were no emotional, behavioral, cognitive, or impulsive issues to warrant this level of care.  She was psychiatrically stable.  Her hypertension did not need the residential setting for medical management.  She had agreed to try naltrexone.  She was engaged in her treatment plan and had a sponsor.  She had the external stressors of her ex-boyfriends frequent attempts to re-engage with her, and the stress of three children. However, she remained motivated towards recovery.  She had a stable and supportive sober support system. She no longer required the restrictive 24/7 residential setting and could have been stepped down to an ambulatory level of care such as intensive outpatient program. Therefore, the residential services from the date of service in question, forward were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 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

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement for positron emission tomography/computed tomography (PET/CT) scan performed. Findings:  The physician reviewer found that the follicular variant of papillary thyroid cancer (FV-PTC) is the most common subtype of papillary thyroid cancer. The medical evidence indicates that FV-PTC patients have a better survival rate than follicular thyroid cancer patients and fewer instances of  lymph node and soft tissue  invasion  than  patients with classical papillary thyroid cancer.  Despite the high incidence in  survival rates, the clinical behavior and outcomes of FV-PTC remain undecided, making it a challenge to establish a standard treatment protocol.  Yu and colleagues note that while most experts will agree that these patients should undergo a total thyroidectomy, the role of adjuvant radioiodine therapy following surgery remains uncertain. Therefore, PET/CT scan may help stratify which patients for whom the benefits of radioiodine therapy may outweigh the risks.  As stated, this study may help identify residual papillary thyroid cancer, either in the deep structures of the neck not visualized by neck ultrasound, or at distant sites that would not be identified either by a high resolution CT or magnetic resonance imaging. The PET/CT scan may help to determine the potential role of radioiodine ablative therapy for this patients treatment. 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 sub-specialty certification in endocrinology, diabetes and metabolism 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 Oncotype Dx prostate cancer testing. Findings:  Three physician reviewers found that the Oncotype DX testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Gene expression analysis utilized to guide management of prostate cancer remains controversial. There is a lack of evidence from well conducted prospective clinical trials demonstrating that the utilization of Oncotype Dx has an impact on patient health outcome. Thus, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 of 3 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 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 reimbursement for Botox injections performed. Findings:  The physician reviewer found that hyperhidrosis is excessive sweating beyond that required to return body temperature to normal. It can be localized or generalized, commonly affecting the axillae, palms, soles or face, and can have a substantial negative effect on a patients quality of life. Santana-Rodriguez and colleagues reported that Botox treatment is a useful alternative to surgical treatment and is safe and effective for focal hyperhidrosis. In sum, there is evidence dating back many years which supports Botox injections as an efficient and appropriate treatment for facial and head hyperhidrosis. Final Result: The reviewers determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Repatha Sureclick. Findings:  The physician reviewer found that based on the records provided for review, the patient is a coronary risk including elevated LDL but no known coronary disease, a low coronary calcium score in 2014 and no documented ischemia on nuclear stress testing performed. In this circumstance of coronary risk without documented coronary ischemia or coronary disease and without a diagnosis of familial homozygous or heterozygous hyperlipidemia treatment with the PCSK9 inhibitor Repatha is not medically necessary and not considered standard accepted practice in the medical community. The diagnoses of familial homozygous or heterozygous hyperlipidemia require not only elevated LDL-cholesterol levels that significantly exceed 180, but also a combination of physical exam findings, a strong family history of coronary disease (younger than 50 years in second-degree relative or aged younger than 55-60 years in first-degree relatives) and documented genetic defects related to cholesterol metabolism according to published criteria. Repatha is a PCSK9 inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol.  This patient does not fit any of those criteria.  PCSK9 inhibitors have not been studied in other patient populations such as this patient. Also, current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting. Finally, there is no documentation that the patient has tried or was intolerant of Zetia, another medication class to reduce cholesterol and improve outcome. Final Result: The reviewers 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: Physician 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly individual psychotherapy (frequency). Findings:  The physician reviewer found that the documentation does not support the medical necessity for the requested frequency of the individual psychotherapy sessions in this clinical setting. The patient showed no evidence of suicidality from the time she transitioned to individual psychotherapy sessions in July 2016. Her mood has been consistently stable. She has been compliant on her medications, and she has gained insight with improved distress tolerance. Her weight remained stable. She reported fewer binge episodes. She was doing well, and she showed no evidence of deterioration after decreasing from weekly to every other week psychotherapy. She continues to show stable weight, energy, sleep, mood, and affect. The provider noted that the patient was continuing to work on interpersonal relationships, her career, and developing adaptive responses to stressors. 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 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 physical therapy twice per week. Findings:  The physician reviewer found that the request for authorization and coverage for physical therapy twice per week is not medically necessary for treatment of this patients symptoms. The documentation indicates that the patient has been evaluated by physical medicine and rehabilitation, pain management, and gynecology specialists. The impression is that the patients condition is low back/sacroiliac related. However, the records report that prior physical therapy has not led to functional improvement. The provider noted that the patient was also treated with prior therapy for pelvic floor dysfunction without improvement. Although a review of the literature reports some beneficial effects for pelvic floor myofascial dysfunction from physical therapy, this patients records do not support the need for pelvic floor therapy. All told, the request for physical therapy twice per week is not medically necessary for treatment of this patients medical condition. 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 physician reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: An enrollee has requested reimbursement and prospective authorization and coverage for applied behavior analysis (ABA) therapy for 40 hours per week from the date of service in question, forward.  Findings:  The physician reviewer found that the submitted records support the medical necessity of the services at issue in this clinical setting.  The correlation between treatment outcomes and treatment intensity is well documented.  In a recent article on the efficacy of ABA , the authors noted a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress.  In this case, the patient appears to have made progress in many areas as over the last several years, but continues to demonstrate impairment in vocal stereotypy, self-stimulation and self-injury.  These persistent struggles are making it difficult for the patient to be successful in more generalized environments. The patient has been authorized for approximately 18 hours per week of direct ABA therapy, which is less than what is typically recommended for optimal response.  The medical evidence supports the services at issue in this clinical setting.  All told, ABA therapy for 40 hours per week from the date of service, forward was and is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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.