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

Nature of Statutory Criteria/Case Summary: A transgender enrollee has requested reimbursement for breast augmentation for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the procedure at issue. The patient underwent sex reassignment surgery with bilateral augmentation mammaplasty.  The patient is well-documented to have gender dysphoria. Thus, her external anatomy should be more consistent with a female than a male. However, a detailed preoperative breast examination was not documented by the surgeon prior to the surgery. In addition, preoperative photographs were not provided to assist in determining the degree of breast development that the patient had following her hormonal therapy. The surgeon states that the patient had very little breast development consistent with Tanner Stage 2. However, there was no documentation supporting this statement prior to her surgery. There is no documentation of preoperative anatomic measurements and no other breast examination details have been provided.  All told, there is insufficient preoperative documentation to adequately characterize the patients breast development. Therefore, the medical necessity of breast augmentation surgery for treatment of the patients gender dysphoria has not been established. In sum, the breast augmentation surgery was not medically necessary for the treatment of this patients gender dysphoria. With regard to whether the procedure at issue is considered reconstructive in nature, there is insufficient clinical documentation to determine if the patients breast development was abnormal for a female. Preoperative photographs and a detailed preoperative breast examination have not been provided. Final Result: The reviewer determined that the procedure at issue was not medically necessary for treatment of the patients medical condition and was not reconstructive in nature. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX reflux management system for treatment of his gastroesophageal reflux disease (GERD). Findings:  Three physician reviewers found that this patient reportedly has GERD but corroborative pH recording results were not provided to support the diagnosis of symptomatic acid reflux. The available records support that he has benefited to a significant degree from acid suppression treatment, and as such cannot be considered medically refractory to acid blocker drugs. Further, the patients EGD described an unremarkable esophagus. Final Result: The reviewers determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and is 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 for residential treatment care from 12/6/16 through 12/13/16. Findings:  The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. By 12/6/16, the records indicate that the patient was no longer a danger to himself or to others. He was not gravely disabled.  He was no longer psychotic.  The patient was cognitively intact and performing activities of daily living. He did not demonstrate a high degree of impulsivity or manic/hypomanic behavior. He was medication compliant.  He had no comorbid medical conditions.  He was psychiatrically stable to the point that he no longer required the confines of a residential setting.  His medications did not require monitoring at the residential level. He was at risk in terms of substance abuse, as evidenced by his declaration that he had no desire to maintain sobriety. However, his home environment was supportive of both his substance abuse recovery and his psychiatric illness. This patient could have continued his treatment at a lower level of care. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX esophageal sphincter augmentation for treatment of the enrollees gastroesophageal reflux disease (GERD) and hiatal hernia. Findings:  Two physician reviewers found that the records support that this patient has acid reflux as based on pH recording. However, she also has a constellation of symptoms that are unlikely due to GERD. In addition, implantation of LINX in this patients clinical setting is not recommended given her documented complaint of dysphagia. Further, endoscopy showed no visible or histologic evidence of esophagitis. Final Result: The reviewers determined that the requested procedure is not likely to be more beneficial for treatment 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 sub-specialty certification in gastroenterology and are 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 digital breast tomosynthesis performed. Findings:  The physician reviewer found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has dense breasts. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Accordingly, the digital breast tomosynthesis performed on 10/10/16 was 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 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. Physician reviewers 1, 2 & 3 are board certified in diagnostic radiology and is 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 cochlear auditory implant for treatment of the enrollees hearing loss. Findings:  The physician reviewer found that bone conduction hearing aids have been traditionally used for conductive hearing losses. However, expanded indications for Bone Anchored Hearing Aid (BAHA) implantations are developing for sensorineural hearing loss as well. Single-sided deafness (SSD) from pathology, such as acoustic neuromas, or sudden sensorineural hearing loss are recent rationales made for bone conduction aids. Reported benefits for SSD patients include better sound localization and better sound clarity. Classic thinking has been that bone stimulates both cochlea simultaneously. If one cochlea does not work, it seems that the functioning cochlea would be fully stimulated or perhaps even overstimulated before effects are seen on the deaf side. Moreover, BAHA is approved by the U.S. Food Drug and Administration for conductive hearing losses and for single-sided sensorineural deafness. Recent reports indicate that persons who hear in only one ear can achieve improved sound localization and clarity of sound using BAHA on the same side of the skull as the hearing loss. In this patient, who is diagnosed with unilateral profound sensorineural hearing loss, BAHA implantation is medically necessary. Therefore, the requested cochlear auditory implant is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested device 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 otolaryngology 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 authorization and coverage for implant neuroelectrodes for treatment of the enrollees lumbar radiculopathy and spondylosis. Findings:  Two physician reviewers found that the use of spinal cord stimulation with implant neuroelectrodes is not considered a first-line therapy. Further, this type of treatment is not recommended prior to evaluation with a thorough psychological evaluation. A preoperative psychological evaluation has been used to predict the successful outcome of spinal cord stimulation. This patients records do not include documentation of surgical or psychological evaluations to determine whether she is an appropriate candidate for the requested procedure. Final Result: The reviewers determined that the service is not likely to be more beneficial for treatment 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 anesthesiology with sub-specialty certification in pain medicine 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 magnetic resonance imaging (MRI) of the lumbar spine. Findings: The physician reviewer found that evidence based medical guidelines support the use of early MRI when signs or symptoms suggest a serious or specific underlying condition is present. The guidelines support imaging following motor vehicle accident when radicular findings are present. This patient was involved in a rear-ended motor vehicle accident with acute onset of lower back pain radiating into the left lower extremity with numbness in the toes. Clinical examination findings documented spinous process tenderness with no focal neurologic deficit. Given the history of trauma and radicular complaints, proceeding with a lumbar spine MRI is medically reasonable and necessary at this time. Final Result: The reviewer determined that the requested procedure is medically necessary for evaluation 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90 mg/400 mg for 12 weeks. Findings:  The physician reviewer found that according to the 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. According to the guidelines, patients with cirrhosis are considered highest priority for treatment. In patients with decompensated cirrhosis, guidelines recommend treatment with Harvoni with ribavirin for 12 weeks, but not Harvoni alone for 12 weeks. This recommendation is based on the SOLAR-2 trial, which demonstrated efficacy in this population. Zepatier is not one of the several AASLD/IDSA recommended regimens for treatment of genotype 1a hepatitis C in patients with decompensated cirrhosis or severe hepatic impairment. Studies of Zepatier have not included patients with this level of liver disease . For these reasons, although treatment is needed in this case, the requested treatment with Harvoni monotherapy for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.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 number one 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 a 12 week extension of Sovaldi, Daklinza and ribavirin. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. However, this patient has started a 12-week course of Sovaldi, Daklinza, and ribavirin. The guidelines state that for treatment-naive and experienced patients with HCV genotype 3 infection in the allograft, including those with compensated cirrhosis: daily daclatasvir (60 mg) plus sofosbuvir (400 mg) with low initial dose of ribavirin (600 mg, increased as tolerated) for 12 weeks is a recommended regimen for patients with hepatitis C virus genotype 3 infection. This applies in this case as the patient is treatment-experienced and has cirrhosis in the allograft. This is based on a study of 77 liver transplant patients receiving Sovaldi with Daklinza (Fontana, et al). Regarding the request to extend therapy in the context of a positive viral load at week 4, the AASLD/IDSA guidelines do not recommend extending therapy on the basis of detectable viral load at any point, stating that the significance of a positive HCV RNA test result at week 4 that remains positive, but lower, at week 6 or week 8 is unknown. No recommendation to stop therapy or extend therapy can be provided at this time. Final Result: The reviewer determined that the requested medications 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 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 Suboxone 8 mg/2 mg. Findings:  The physician reviewer found that in the documentation available for review, this patients chronic pain is considered palliative in nature and treatment. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in this patients case, not all non-opioid treatment options have been utilized. Behavior therapy has not been discussed or noted to be completed despite much research to support its use. Also, there are other non-pure mu agonist that have long lasting duration that may be available to the patient. Further, there is no documentation from a Crohns disease or autoimmune specialist available for review. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter closure of patent foramen ovale (PFO) and left atrial appendage for treatment of her cerebrovascular accident (CVA) and PFO. Findings:  Two physician reviewers found that based on review of the recent literature, there is a paucity of data demonstrating a benefit of PFO closure over medical therapy. Li and colleagues found that the combined data from randomized controlled trials have shown no statistically significant differences between transcatheter device closure of a PFO and medical therapy in the prevention of ischemic stroke after a cryptogenic stroke in the setting of a PFO. In addition, the RESPECT trial in the intention-to-treat analysis did not report a benefit of transcatheter closure over medical therapy in the treatment of PFO. Given the lack of strong statistical support for a benefit of transcatheter PFO closure over medical therapy, the requested transcatheter closure of PFO and left atrial appendage are not 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 procedures are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and is 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: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential psychiatric level of care services provided from date of dispute and forward. Findings:  The physician reviewer found that the medical evidence and the documentation provided do not support the medical necessity of the services at issue in this clinical setting. Outpatient treatment and least restrictive options are considered first lines of care as referenced by The American Academy of Child and Adolescent Psychiatry. The standard of care for treatment of children and adolescents should be in the least restrictive setting as possible in order to maintain and foster natural supports. It is further recommended that children should be treated in the setting that is least restrictive and disruptive to their lives. Inpatient or residential treatment is indicated only in emergencies or for children who have not responded to efforts at outpatient treatment. In a study children in intensive in-home therapy were more likely to live with family, make progress in school, not have trouble with the law, and have better placement permanence than youth who were treated in residential treatment facilities. The progress notes indicate that by the date of dispute, the patient was cooperative with her treatment plan. She was noted to be providing and accepting good feedback while in group therapy. She did not display dangerous behaviors. There were no documentation as to aggressive behaviors towards peers or staff during her stay. The records do not indicate that the patient had any symptoms that would have necessitated continued residential care. The documentation indicates that the patient was acquiring coping skills and was not having any attempts to harm herself.  Her family was also involved actively in her treatment.  Her treatment goals could be accomplished on an outpatient basis. She was receiving DBT and this was recommended on discharge. All told, residential psychiatric level of care services provided from date of dispute forward were not and are not medically necessary for treatment of this patients medical condition.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 with sub-specialty certification in child and adolescent 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.