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

The patient has requested authorization and coverage for facial feminization surgeries. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that, for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. WPATHs SOC further noted that, other surgeries for assisting in body feminization includerhinoplastyfacial bone reduction, face-lift, and blepharoplasty. This patients providers report that the patient experiences anxiety and depression from the presence of masculine facial features. The patient is committed to feminine transformation, given her treatment history with hormone therapy. The patient meets the WPATH criteria for gender dysphoria and indication for facial feminization surgery based upon clinical documentation of persistent gender dysphoria related to masculine facial features associated with social dysfunction. The requested facial feminization surgeries are medically necessary to help alleviate the patients gender dysphoria and related distress. Therefore, the requested facial feminization surgeries 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 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: The patient has requested authorization and coverage for cryosurgical ablation (CPT 20983). This patient has metastatic non-small cell lung cancer with the therapeutic intent of palliation and symptom control. Based on the clinic notes, the patients symptoms are not adequately controlled with systemic palliative therapies. She has one region of increasing disease in the right posterior rib region as described by the most recent positron emission tomography/computed tomography (PET/CT). This area is associated with persistent pain. Pain alleviation is an acceptable standard goal for cancer care. There are multiple accepted modalities for focal treatment of tumor to provide symptom management. CT guided cryosurgical ablation is an effective palliative local therapy that can achieve symptom management due to progressive disease. Therefore, the requested cryosurgical ablation (CPT 20983) is 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 oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for whole body F-18 fluciclovine (HCPCS A9588) positron emission tomography (PET) with computed tomography (CT) for attenuation (CPT 78816). The National Comprehensive Cancer Network (NCCN) guidelines on prostate cancer state that F-18 fluciclovine PET/CT scan may be used to detect small volume disease in soft tissue. The American Urological Association (AUA) noted that there is limited data to support the utility of F-18 PET with CT to detect distant metastases. This patients records document a PSA of 5.0 in 2019 after treatment with radiation therapy in 2017 and PSA nadir in 2018. Based on the current data, F-18 PET/CT scan is not considered a generally accepted standard of care for management of patients with PSA recurrence after radiation. The standard of care in this clinical setting is a bone scan and CT to rule out metastasis and a prostate biopsy to evaluate for local recurrence if the metastatic work-up is negative. Therefore, the requested whole body F-18 fluciclovine (HCPCS A9588) PET with CT for attenuation (CPT 78816) is not medically necessary for evaluation 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 urology 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 enrollee is requesting authorization and coverage for a three month refill of Effexor 150mg, a three month refill of Seroquel 200mg, individual psychotherapy every two weeks, and monthly visits with a psychiatrist. The enrollee has chronic recurrent depression and anxiety, exacerbated by recent stressors. Her symptoms were relatively well-managed until she had a panic attack in March. Subsequently, her medications were changed and her mood worsened causing her to have panic attacks every week. She started having suicidal ideations since she was getting two weeks supplies of medication, and wanted more.  She was scheduled for a psychiatry follow-up for a second opinion, and larger supplies of Effexor XR and Seroquel but was unable to follow through with the appointment. She had not taken Seroquel or Effexor XR for three days and felt withdrawal symptoms, as a result. Although the enrollee continued to display significant depression and multiple neuro-vegetative signs, she did not want to restart an intensive outpatient program. She indicated she was willing to restart the medications and requested more frequent appointments. Review of the record indicates the enrollees overall functional ability was mildly to moderately impaired. Her physician indicated mild psychomotor agitation, but no abnormal movements or tardive dyskinesia symptoms.  The enrollees speech was normal and coherent, and her thought process was logical and goal-directed.  The enrollee vocalized no suicidal ideation, plan or intent and her insight/judgment was average.  Her symptoms were exacerbated by recent stressors, and she was in medication withdrawal. She was not a danger to herself.  Medical records indicate Seroquel was prescribed for the enrollee for major depressive disorder.  However, the request for three refills is excessive because the enrollee is evaluated monthly by her psychiatrist. The records indicate the enrollee was scheduled for individual psychotherapy every two weeks, which is medically necessary for this enrollee.  The medical literature also indicates the psychiatrist should determine the least restrictive setting for treatment that will be most likely to address the enrollees safety and promote improvement in the enrollees condition, including the frequency of visits.  The records indicate a request for monthly visits with a psychiatrist, which is medically necessary for this enrollee.  Final Result: The reviewer determined that the requested service is partially medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The enrollee requested reimbursement for serological antibody testing for Helicobacter pylori. The enrollee was evaluated for complaints of stomach pain/burping. She reported stomach pain that occurred ten days prior early in the morning.  The enrollee indicated she began vomiting later that day. Her abdominal pain was worse at night. Her physician ordered labs to help determine the cause of her abdominal pain. Helicobacter pylori testing was performed. The enrollee has epigastric pain, which can be explained by gastritis or peptic ulcer disease caused by Helicobacter pylori. Serology can test for Helicobacter pylori. Literature notes Helicobacter pylori infection can be diagnosed by invasive techniques requiring endoscopy and biopsy, and by non-invasive techniques, such as serology. Some non-invasive tests, such as serology, are markers of exposure to Helicobacter pylori but do not indicate if there is an active infection; these are called passive tests. Non-invasive, test-and-treat strategies are widely recommended in the primary care setting. This enrollees age and symptoms are appropriate for the use of serological testing for Helicobacter pylori. Had the test been positive, the enrollee would have been treated for Helicobacter pylori. If her symptoms improved, she would be able to avoid an esophagogastroduodenoscopy; which is more invasive.Final Result: Two of the three reviewers determined that the requested services are likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in gastroenterology 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

The patient has been diagnosed with left knee pain and left knee osteoarthritis. The patient reported left knee pain. She has failed treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and arthroscopic left knee surgery. The provider noted the patient had a prior adverse reaction to a cortisone injection. The patient has requested reimbursement for four Supartz injections that were received. 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. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. Researchers found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patients options were limited. The patient had an anaphylactic reaction to cortisone in the past and had tried and failed other conservative treatments with the alternative being a total knee arthroplasty. The medical evidence supports the services at issue. Therefore, four Supartz injections that were received were medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested services 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 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

The enrollee requested authorization and coverage for surgical insertion of a Superion interspinous process spacer for chronic, intractable low back pain and neurogenic claudication to the bilateral lower extremities. She cannot walk moderate distances in excess of 50 to 100 feet without severe pain. Her pain is impairing her ability to complete the basic activities of daily living. A magnetic resonance imaging scan shows evidence of lumbar spinal stenosis. Other radiographic studies show no spinal instability or remarkable scoliosis. The enrollee has failed over six months of conservative treatment, including physical therapy, home-based exercises, massage, chiropractic treatment, acupuncture, non-steroidal anti-inflammatory medications, over-the-counter non-prescription transdermal medications, oral opioids, epidural steroid injections, and attempts at bracing. Her provider indicates continued conservative treatment is not expected to yield substantive clinical improvement. Although surgical decompression is the other treatment option, the enrollee is not a good candidate for such an invasive surgical procedure, and the enrollee does not want this procedure at this time. Her physician recommended indirect decompression to the L4-L5 level. The use of an interspinous process spacer may be applicable in cases of single level stenosis. However, due to the disk space degeneration at L5-S1 and the multiple levels of degenerative spondylosis, this enrollee is not a good candidate for a Superion interspinous process spacer. A review of the literature regarding the superior interspinous spacer device, and other well-established surgical decompression procedures, shows a lack of large, randomized studies, which indicate Superion is more beneficial than other surgical treatments. The use of the Superion interspinous spacer has not yet been established as a standard of care, as superior to, or considered as first-line over other surgical options. Studies showed the use of interspinous devices, in those with or without Grade 1 spondylolisthesis, demonstrated no statistical difference in outcomes. Literature notes interspinous process spacers demonstrated no superiority in outcomes compared with traditional bony decompression. Evidence showed fewer surgical complications, but significantly higher re-operation rates.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Two reviewers are board certified in pain management and one reviewer is board certified in neurological surgery 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

The patient has requested authorization and coverage for Vyvanse. There is evidence-based literature to support the use of Vyvanse for the treatment of attention deficit hyperactivity disorder and binge eating disorder. This patients diagnoses include chronic fatigue syndrome, systemic lupus erythematosus and Sjogrens syndrome. There is a lack of peer-reviewed, evidence-based literature or guidelines to support the use of Vyvanse for the treatment of chronic fatigue associated with autoimmune disease. Therefore, the requested Vyvanse 20 mg is not medically necessary for 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement the genetic test DecisionDx-Melanoma. Currently, the DecisionDx-Melanoma genetic assay is not considered routine standard of care and is not endorsed by the National Comprehensive Cancer Network (NCCN) guidelines. There is a limited data to support its use in the care of patients with melanomas to effect health outcomes. There is literature to suggest it may be beneficial for patients with melanomas to predict whether there is risk for metastasis based on phenotype. However, there is a lack of data demonstrating improved patient health outcomes with guidance from the test results. The standard of care would require a wide local excision and follow-up skin surveillance. All told, the genetic test DecisionDx-Melanoma was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the genetic test DecisionDx-Melanoma was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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: Physician reviewers 1, 2, and 3 are board certified in dermatology 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:  The enrollee is requesting authorization and coverage for the medication, estradiol 0.01% cream for complaints of burning with urination and suprapubic pain over the last two months. A urinalysis showed a white blood cell count of six to ten. Urine culture showed urogenital flora, consistent with contamination. There was no evidence of urinary tract infection. The prescriber diagnosed atrophic urethritis and recommended locally acting Estrace (estradiol) cream to decrease the side effects from oral formulations. This enrollee was prescribed topical estrogen cream for the treatment of atrophic urethritis. The enrollee was not prescribed Vagifem tablets because it is not the best treatment for her condition. This enrollees main complaint is burning pain with urination. Her urine culture did not indicate a urinary tract infection, and she did not have any other urinary symptoms (hematuria, urgency, hesitancy, incomplete emptying, enuresis, lower back or flank pain). Therefore, the next most likely diagnosis, given her age, is atrophic urethritis, also known as genitourinary syndrome of menopause.  The enrollees physician appropriately prescribed a topical estrogen cream for the enrollee to apply locally to the opening of her urethra. The medication Vagifem would not help alleviate this enrollees symptoms as well as the topical treatment. Typically, the best results occur when estrogen comes into direct contact with the urethra or any other specific area in need of treatment. While vaginal absorption of the Vagifem estrogen tablet may eventually have some benefits that extend to the urethra, typically, much higher doses of estrogen are needed for the benefits of local estrogen to transfer to the lower urinary tract. A study showed a minimum dose of 25 milligrams of estrogen, vaginally, was needed to see any beneficial changes in the urethral epithelial cells. This higher dosage of estrogen resulted in systemic increases in estrogen levels. There is concern that long-term systemic absorption of estrogen can increase the risk of endometrial cancer and venous thrombotic events. These risks are what the enrollees physician was trying to avoid when she wrote in her notes that she was using a topical estrogen, rather than an oral hormone supplementation, which has significantly higher risks associated with it.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 obstetrics and gynecology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for a computed tomography (CT) of the heart without contrast. Based on the records provided, this patient presented with a strong family history of myocardial infarction and symptoms of pain, pressure, and heaviness in the legs. In this circumstance, guidelines for the management of cardiac risk established by the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) do not support routine advanced lipoprotein testing. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk. In addition, treatment changes or additions based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Therefore, the CT of the heart without contrast was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the CT of the heart without contrast was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty 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.