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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cyst removal and bone graft. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition and are not reconstructive in nature.  Findings: The documentation provided does not support the medical necessity of the requested services at this time. The patient has a lesion within his anterior maxilla, which is in need of treatment. However, the records do not indicate that a current biopsy of the lesion has been performed. In this clinical setting, standard of care dictates that an incisional biopsy should be performed prior to the surgery as this will guide final and definitive therapy.  The records indicate that the differential for this lesion is broad and a final definitive surgical plan for resection and reconstruction is ideally made after a biopsy and a histopathology confirming the nature of the lesion. Should the biopsy indicate that the lesion is an odontogenic keratocyst, options for treatment can include resection and reconstruction versus marsupialization which would be less invasive for this patient. Given that the nature of the patients lesion is unknown, the cyst removal and bone graft have not been established as medically necessary until a definitive diagnosis can be provided. With regards to the whether the requested services are reconstructive in nature, the submitted records do not support whether or not the patients lesion constitutes an abnormal structure of the body at this time.  A recent biopsy has not been performed or provided and as noted above, a definitive diagnosis would need to be indicated prior to the requested surgery. For these reasons, the submitted documentation does not support that the requested cyst removal and bone graft are reconstructive in nature.Final Result: The reviewer determined that 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.Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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 reimbursement for the hospital stay. In this case, the hospital stay is supported as medically necessary for treatment of this patients medical condition. The patient was at risk for recurrence of UTI due to her prior ureteral reimplantation and history or urinary tract abnormalities. She had started to respond to antibiotic, but had right flank tenderness on physical examination and required Norco for control of dull flank pain at 7/10. She had just transitioned to oral Levaquin therapy. For these reasons, the hospital stay is supported as medically necessary for the treatment of the patients urinary tract infection and pyelonephritis.Final Result: The reviewer 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: 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Dexilant 60 mg twice daily. The Health Plan has denied this request indicating that the requested medication dosage is not medically necessary for treatment of the enrollees gastroesophageal reflux disease (GERD).Findings:  The physician reviewer found that based on current medical literature, Dexilant 60 mg twice daily is not supported as medically necessary. A comparison of multiple proton pump inhibitors (PPIs), including omeprazole, lansoprazole, and pantoprazole, has found no difference in control and healing of GERD. Dexilant, unlike all other proton pump inhibitors, 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 and once daily dosing is recommended. Additionally, the use of Dexilant at the requested dose of 60 mg twice daily has not been approved by the U.S. Food and Drug Administration and the prescribing information for Dexilant states that use of Dexilant 60 mg twice daily is associated with severe adverse effects including hypertension (Dexilant package insert).  For these reasons, authorization and coverage for Dexilant 60 mg twice daily is not supported as medically necessary for the treatment of the patients GERD. Final Result: The reviewer determined that requested medication dosage 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 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 parent of an enrollee has requested authorization and coverage for 60 minutes of individual speech therapy and 30 minutes of group speech therapy per week. This patients school speech evaluation shows ongoing problems with inferences and social language. In the medical literature, authors reported that it is difficult to assess pragmatic language and recommends using several tests to better determine if speech therapy is indicated. Researchers showed that assessing pragmatic language requires in vivo pragmatic language assessment as well as formalized testing. The description of this patients difficulty with inferences and social language suggests the need for ongoing speech therapy. The testing from school revealed an overall average score, but noted problems in several areas. Given these findings, this patient requires speech therapy to address pragmatic language problems two times per week. Accordingly, the requested 60 minutes of individual speech therapy and 30 minutes of group speech therapy per week is supported as 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for incontinence medical supplies. The submitted documentation fails to demonstrate the medical necessity of the requested equipment. The treatment for mixed type urinary incontinence starts with lifestyle modifications, pelvic floor muscle exercises, and bladder training. If initial treatments are not effective, women are then treated based on their predominant symptoms. In this case, the request is for urinary incontinence supplies. The records do not include a detailed history of the patients urinary complaints. It is unclear if any diagnostic studies have been done or are even necessary. Furthermore, there is no clear documentation of her predominant symptoms or failed previous treatments. All told, the requested incontinence medical supplies are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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 reimbursement for the Afirma Gene Expression Classifier (GEC) testing. The Bethesda System recommends a diagnostic hemithyroidectomy for this type of nodule. The recent American Thyroid Association guidelines state that for nodules with atypical of undetermined significance cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat fine needle aspiration (FNA) or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. If the genetic test is suspicious, the risk of malignancy increases to 40% and the risk of malignancy decreases to less than 6% with benign findings. In this case, the result of the Afirma GEC was suspicious for malignancy. This increases the patients risk of malignancy to 40%. This information was important to determine the decision whether to perform thyroidectomy. For these reasons, the Afirma GEC testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the Afirma GEC testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 intravenous immune globulin (IVIG). Findings:  The physician reviewer found that selective antibody deficiency with normal serum IgG concentrations is a deficiency of specific antibody response to polysaccharide antigens with intact response to protein antigens and normal serum level of IgG and IgG subclass. IgG replacement therapy with IVIG or subcutaneous immunoglobulin preparations is a treatment option for this group of patients with recurrent infections that persist after immunizing and antibiotic treatment. Evaluation of serum antibody titers to pneumococcus includes obtaining serum antibody titer prior to immunization, and then again three to six weeks after immunization with polyvalent pneumococcal polysaccharide vaccine. A failed overall challenge test is defined as failure in seven or more serotypes (30% or more) in patients age six years or older. Despite the fact that this patient has normal levels of IgG, her response was abnormal to vaccine challenge with post-vaccination pneumococcal (polysaccharide) titers. In addition, the patient also has a history of frequent, significant infections requiring antibiotics and hospitalization. The current medical evidence supports the requested medication in this clinical setting. Therefore, IVIG is medically necessary for the treatment of this patient. 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 internal medicine and allergy and immunology 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 reimbursement for gene panel testing. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee with a history of aplastic anemia.Findings:  Prior to transplantation, it is standard practice to check for telomere length for the diagnosis of dyskeratosis congenita (DKC). Knowing this information prior to transplantation is important because it can change the conditioning regimen required for bone marrow transplantation. In addition, individuals diagnosed with DKC are also at risk for other types of cancers and diseases. Thus, it would be an important assessment to make in terms of cancer screening and prevention. Currently, there is very limited available standard therapy. Testing for all conditions that can cause aplastic anemia is standard of care and it includes testing for telomere length.  Patients identified as having DKC may respond to a trial of androgen therapy and therefore, for treatment options it is imperative to know if DKC is present.  In addition, DKC can have long lasting medical problems, which would need continued monitoring and screening. For the reasons noted above, the gene panel testing was likely to have been of greater benefit than the available methods of evaluating this patient.Final Result: All three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  All three reviewers are board certified in pediatrics with sub-specialty certification in pediatric hematology-oncology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial laser hair removal. Findings:  The physician reviewer found that Facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. The record notes that hormone therapy has not been effective in treating this patients excessive facial hair. She has reported anxiety over being misgendered despite hormone therapy. Therefore, facial laser hair removal is medically necessary for treatment of this patients gender dysphoria.With regards to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is considered an abnormal body structure. It would be abnormal for a female to have terminal hair on the face. The patients abnormal appearance is the result of gender dysphoria, a disease classified in the Diagnostic and Statistical Manual of Mental Disorders. Facial laser hair removal can provide substantial improvement in the appearance of terminal hair and create a normal appearance to the best extent possible. Additionally, facial laser hair removal would also provide more than a minimal improvement in the appearance of this patient as well as improve the patients emotional function. For these reasons, facial laser hair removal is reconstructive in nature. 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 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 individual acupuncture treatments, twice per week for five weeks followed by weekly individual acupuncture treatment for up to sixteen weeks. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. Findings: The medical literature supports that acupuncture has been found to be effective when compared to no treatment for short term pain relief in chronic low back pain, chronic headaches and neck pain. Additionally, there is some evidence that acupuncture has been shown to provide and add benefit alongside conventional therapy. However, in this clinical setting, the documentation provided does not support the medical necessity of the requested services. In this case, the records indicate that this patient has already completed sessions without any extraordinary circumstances noted. The records do not report objective or specific gains obtained with the acupuncture treatment provided. The patient is requesting additional acupuncture sessions. There is a lack of evidence in peer reviewed literature for the efficacy of long term acupuncture therapy especially in the absence of measurable objective gains. Consequently, individual acupuncture treatments, twice per week for five weeks followed by weekly individual acupuncture treatment for up to sixteen weeks is not supported as medically necessary for treatment of her 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 reviewer is board certified in oriental 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the wearable cardioverter defibrillator. Findings:  Two of the three physician reviewers found the records document recent onset non-ischemic cardiomyopathy with an ejection fraction of 35%. There is some likelihood of recovery of left ventricular function in this instance over the initial three month period with evidence-based medical therapy. As he is at the borderline ejection fraction, any improvement in ejection fraction with medical therapy may obviate the need for an implantable defibrillator. This patient is at risk for malignant arrhythmia and sudden death while his ejection fraction is low. A wearable cardioverter defibrillator can provide temporary protection from sudden death due to arrhythmia in this patient population during this interim period. Per the medical evidence, the wearable defibrillator was an appropriate and reasonable alternative in this clinical setting. Thus, the wearable cardioverter defibrillator was likely to have been more effective than other available treatment options. Final Result: The reviewers determined that the device at issue was 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 authorization and coverage for Mavyret 100-400 mg. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 3 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. The ENDURANCE-3 trial showed a 95% cure rate with eight weeks of treatment The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.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 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.