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. Facial feminization surgery is medically necessary for many transgender women to help alleviate the psychological distress they experience related to gender dysphoria. Moreover, the World Professional Association for Transgender Health (WPATH) supports facial feminization surgery in well-selected patients. WPATH noted that non-genital surgical procedures are oftentimes of greater practical significance in the patients daily life than reconstruction of the genitals. The guidelines further report that, these reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. This 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. Her provider has recommended additional procedures including facial feminization surgeries with forehead, brow and eye orbital, upper lip, and rhinoplasty. Given the support from WPATH, 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: Upheld Decision of Health Plan

The patients parent has requested reimbursement and prospective authorization and coverage for eight hours per month of clinical team meetings. Although the patients behavior is described by the provider as a safety concern and the parent report on the Vineland Adaptive Behavior Scales score is listed as elevated in the most recent treatment authorization request, the data does not support these claims. The rate of the enrollees behavior is extremely low, suggesting they are not as problematic as described. The patient has also met or nearly met many of her goals. Due to the lack of significant problematic behavior and the skills that the patient has already acquired, the services at issue were not and are not medically necessary for the 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 a licensed B.C.B.A, board certified in psychology, 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

The patient has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation (TMS). TMS therapy is U.S. Food and Drug Administration (FDA) approved for treating patients in the acute phase of major depressive disorder. There have been some small studies evaluating the use of TMS in bipolar disorder, but the data have not revealed statistically significant remission rates. There are ongoing studies investigating the use of TMS for the depressed phase of bipolar disorder, but not have yet demonstrated evidence that would support the use of TMS for bipolar disorder. This patient has a history of bipolar disorder characterized by episodes of hypomania and depression as well as anxiety. However, TMS is not recommended for the treatment of bipolar disorder based on consensus statements and lack of clinical trials demonstrating long-term safety and efficacy. All told, the TMS treatment provided was not and is 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

An enrollee has requested authorization and coverage for methylergonovine maleate 0.2 mg tablet, three (3) times daily (90 tablets/30 day supply).The submitted documentation supports that the requested medication is medically necessary. Methylergonovine maleate is an ergot derivative with vasoconstrictive properties, and it has been cited as an effective treatment for vascular headaches, more specifically migraines. Studies of patients who have used methylergonovine maleate have found that patients reported significant relief from migraines. In this case, the patient has been struggling with cycles of severe headache pain, and she has been on multiple traditional medical therapies for the treatment of her migraines without relief. Under these circumstances, the requested methylergonovine maleate 0.2 mg tablet, three (3) times daily (90 tablets/30 day supply) is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patients parent has requested authorization and coverage for visual communication analysis with self-determination theory. Researchers concluded that there is limited evidence that verbally based and ACC interventions improve spoken and non-verbal communication in minimally verbal children with ASD [autism spectrum disorder]. Based on the lack of evidence in peer-reviewed medical literature, there is insufficient support to demonstrate evidence of effectiveness for visual communication analysis with self-determination theory therapy. This patient has a diagnosis of ASD. The patient is being treated with applied behavioral analysis (ABA), which is considered the standard of care for their condition. All told, the requested visual communication analysis with self-determination theory is not medically necessary for 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 optometry and a certified optometric vision therapist 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

The patients parent has requested authorization and coverage for visual communication analysis with self-determination theory. This patient has a diagnosis of autism spectrum disorder (ASD). She is being treated with applied behavioral analysis (ABA), which is considered the standard of care for her condition. Researchers concluded that there is limited evidence that verbally based and ACC interventions improve spoken and non-verbal communication in minimally verbal children with ASD. Overall, there is a paucity of evidence in the peer-reviewed medical literature to support visual communication analysis with self-determination theory therapy for patients with ASD. For these reasons, the requested visual communication analysis with self-determination theory is not medically necessary for 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 optometry and a certified optometric vision therapist 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

The enrollee is requesting authorization and coverage for laser hair removal for body hair. The enrollee is a transgender female with gender dysphoria. She is requesting coverage for laser hair removal because hormone therapy and electrolysis have not generated the desired results, as she has thick hair that grows back quickly. Considering the previous failed medication treatment, the continued gender dysphoria, and the diagnosis of hirsutism, the requested laser hair removal treatment is recommended. A professional society supports the use of laser hair removal for gender dysphoria. Studies shows that hair removal is associated with decreased distress and increased subjective well-being. This study demonstrates a significant association between hair removal services and depression symptoms, anxiety symptoms, and situational body image dysphoria. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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

The enrollee requested authorization and coverage for the requested confocal laser endomicroscopy. The enrollee has Barretts esophagus and gastroesophageal reflux disease. He has abdominal pain and worsening esophageal pain with exertion. His gastroenterologist recommended the confocal laser endomicroscopy procedure. The enrollees case manager reports the procedure would provide significant diagnostic information and aid in future treatment for the enrollee. A professional society indicates further studies are needed to evaluate the applicability and practicality of confocal laser endomicroscopy. Although current studies appear promising, these studies have primarily been conducted in academic centers; therefore, how they will apply in non-academic settings is not known. More studies are needed to evaluate the learning curve of confocal laser endomicroscopy image interpretation, use of confocal laser endomicroscopy devices, and how much additional time is needed to perform the procedure. Limitations of confocal laser endomicroscopy include the lack of proven efficacy, compared with other widely available advanced imaging techniques, and the need for either intravenous or topical contrast agents. Final Result: Two of the three reviewers determined that the requested service is not likely to be 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Privigen (J1459) 80 units every four weeks. Chronic inflammatory demyelinating polyneuropathy (CIDP) is an autoimmune condition that affects the nervous system. The condition can cause intermittent exacerbations due to the demyelination of nerves and nerve roots. The use of intravenous immunoglobulin (IVIG) is the mainstay of the treatment of CIDP and is considered the standard of care for management of the condition. The records provided for review document that this patients treatment has included duloxetine, steroids, and gabapentin without substantial improvement. Since other treatments have failed, IVIG with Privigen is appropriate. Accordingly, the requested Privigen (J1459) 80 units every four weeks is medically necessary for 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for NeuroPace RNS brain neurostimulator. Anti-epileptic drugs are the first-line therapy for epilepsy. Patients who do not become seizure-free after using two appropriately chosen anti-epileptic drugs at therapeutic doses are unlikely to be seizure-free by using medications alone, and the epilepsy is termed pharmacoresistant. Additional treatment options include diet therapy, surgical resection, and neurostimulation (Starnes, et al.). A responsive neurostimulation (RNS) device is a closed-loop device that delivers targeted stimulation to seizure focus and abort seizure activity. Researchers reported the successful treatment of a patient with a seizure onset in the eloquent cortex of the left temporal neocortex, with a reduction from daily seizures to auras only a few times per week at the six-month follow-up. Similarly, another study reported using RNS in a patient with independently hemispheric seizure onset, and in a patient with seizure onset in the eloquent cortex in the left frontal and parietal lobes. The authors found greater than 80% reduction in seizure frequency in both patients. In this case, the patient has intractable focal epilepsy. He underwent evaluation at an epilepsy center and his work-up demonstrated a right central lesion. The patient has failed multiple medications to control his seizures. Given the support in the medical literature, the requested subdural implantation of a NeuroPace RNS brain neurostimulator (CPT code 64568) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested subdural implantation of a NeuroPace RNS brain neurostimulator (CPT code 64568) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 neurology 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 patient has been diagnosed with osteoarthritis of both knees. The patient reported bilateral knee pain. Physical examination findings included tenderness over the right knee medial joint line. Patellar grind tests were positive in bilateral knees. The patient has previously been treated with cortisone injections and physical therapy, with minimal improvement. The provider noted that the previous hyaluronic acid injections provided good results for the patient. The patient has requested authorization and coverage for Hyaluronan (Euflexxa) injections (J7323) in both knees. The Health Plan denied the request and reported that the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Hyaluronan (Euflexxa) injections (J7323) in both knees are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of good response to prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Hyaluronan (Euflexxa) injections (J7323) in both knees are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Kyprolis, 70 mg per square meter (m2), to be administered on days 1, 8 and 15, and the cycle repeated every four weeks.The medical literature does not support that the requested medication is medically necessary. Carfilzomib (Kyprolis) can be used as an appropriate standard of care for relapsed refractory multiple myeloma at a number of doses and in combination with a number of regimens. Dosing of carfilzomib at 70 mg per meter squared weekly, for three weeks out of every four, has been demonstrated to be efficacious in combination with dexamethasone and this combination and dose is considered acceptable as a standard of care. However, the proposed regimen of carfilzomib at 70 mg meter squared in combination with cyclophosphamide (brand name Cytoxan) and dexamethasone is currently under investigation. This regimen has been studied in a phase 1/2 study and demonstrated promising activity and safety. The regimen combination of carfilzomib, dexamethasone and Cytoxan has not yet been approved as a standard of care combination regimen for the treatment of relapsed refractory multiple myeloma. Use of this regimen would be considered investigational and therefore not medically necessary according to current standards of care for the treatment of relapsed refractory multiple myeloma. Accordingly, the requested dosage of 70 mg per square meter (m2) of Kyprolis, to be administered on Days 1, 8, and 15, and the cycle repeated every four weeks, is not medically necessary to treat 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 internal medicine, with subspecialty certification in medical 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with primary osteoarthritis of the left knee. An x-ray of the left knee revealed mild tricompartmental osteoarthritis. The patient received a left knee corticosteroid injection. The patient reported left knee pain. Physical examination findings included tenderness to palpation over the left knee joint lines and facets. Prior treatment included left knee arthroscopy in 2015 and physical therapy. The patient has requested authorization and coverage for Hyaluronan (Euflexxa) injections (J7323) in the left knee. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Hyaluronan (Euflexxa) injections (J7323) in the left knee are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Hyaluronan (Euflexxa) injections (J7323) in the left knee are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.