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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast augmentation. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that, Non-genital surgical procedures notably breast augmentation are often of greater practical significance in the patients daily life than reconstruction of the genitals. These reconstructive procedures are not optional in any meaningful sense but are understood to be medically necessary for the treatment of the diagnosed condition. The WPATH further noted that, other surgeries for assisting in body feminization include Breast/chest surgery: augmentation mammoplasty (implants/lipofilling). The records provided for review report that this patient has gender dysphoria related to her breasts and her providers have recommended breast augmentation to address her gender dysphoria. The available documentation supports that the patient is likely benefit from surgery as a treatment for her gender dysphoria. Moreover, the requested procedure is in accordance with the generally accepted standards of mental health and substance use disorder care, and clinically appropriate in terms of type, frequency, extent, site, and duration. Given these findings, the requested breast augmentation 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 psychiatry with expertise in transgender health 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 parent of an enrollee has requested authorization and coverage for Omnitrope injection 10 mg/1.5 mL cartridge.The U.S. Food and Drug Administration (FDA) has approved somatotropin (HGH) to treat ISS, defined as a standing height below -2.25 SDs without identifiable cause. Standard of pediatric endocrine care for suspected growth disorders includes brain magnetic resonance imaging (MRI) with and without gadolinium contrast and standard provocative testing for endogenous growth hormone release. In this case, the patient has not met the FDA-approved indications or generally accepted indications for somatotropin. The patients height is within two SDs of the mean for his age and sex. Based on BA of 12 years and 6 months and height of 140.6 cm, the patients predicted adult height is within the normal range for North American men. The patients growth velocity was normal prior to initiation of HGH therapy. Therefore, the requested Omnitrope injection 10 mg/1.5 mL cartridge is not medically necessary for treatment of 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 breast augmentation. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that, Non-genital surgical proceduresnotably breast augmentationare often of greater practical significance in the patients daily life than reconstruction of the genitalsThese reconstructive procedures are not optional in any meaningful sense but are understood to be medically necessary for the treatment of the diagnosed condition. The WPATH further noted that, other surgeries for assisting in body feminization include Breast/chest surgery: augmentation mammoplasty (implants/lipofilling). Breast augmentation is often a medically necessary treatment for gender dysphoria. However, this patients records do not include documentation from the patients providers supporting that the requested breast augmentation procedure will help address the patients diagnosis of gender dysphoria. Moreover, the available documentation does not establish that the requested breast augmentation procedure is in accordance with the generally accepted standards of mental health and substance use disorder care, and clinically appropriate in terms of type, frequency, extent, site, and duration. Given these findings, the requested breast augmentation 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 psychiatry with expertise in transgender health and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for alcohol injections. The records provided for review document that this patient has a history of painful neuroma to the third interspace of the left foot. The patient underwent alcohol sclerosing injections to the neuroma. The records indicate that the patient has received six alcohol sclerosing injections to the third interspace on the left foot. There is limited information regarding previous therapies. Based on current medical literature and guidelines, alcohol sclerosing injections are not considered the standard of care for the treatment of a Mortons neuroma. The recommended therapies include orthotics with metatarsal and or neuroma pads, shoe gear modification, local steroid injections, and surgical excision. Overall, the available studies suggest that further studies are needed to determine whether alcohol sclerosing injections have a role in the treatment of patients with Mortons neuroma. Therefore, the alcohol injections were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the alcohol injections were 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 services at issue were 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 reviewer 1 is a licensed D.P.M., board certified in podiatric surgery, and is actively practicing. Physician reviewer 2 is a licensed D.P.M., board certified in podiatric surgery, and is actively practicing. Physician reviewer 3 is a licensed D.P.M., board certified in podiatric surgery, 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 a Monovisc injection in the left knee.An exhaustive review of the current medical literature pertaining to viscosupplemention reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, the patient has tried NSAIDs, corticosteroid injection, and physical therapy. The patients young age is a relative contraindication to joint replacement surgery. Further, the patients options are limited. The provider has recommended viscosupplementation with Monovisc injection for pain relief and postponing the need for joint replacement. Therefore, the requested Monovisc injection in the left knee is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 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: The patient has requested authorization and coverage for proton beam therapy. Per the medical literature, there is a lack of clinical data suggesting that proton beam radiation therapy is associated with a clinical benefit in the treatment of prostate cancer. Researchers note that the major categories of radiotherapy for the treatment of prostate cancer are external beam radiotherapy (EBRT), which includes intensity modulated radiotherapy (IMRT), and brachytherapy. The American Society of Radiation Oncology (ASTRO) notes that proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. In this clinical setting, given the lack of evidence to support the use of proton beam therapy, the requested services are not medically indicated. Therefore, proton beam therapy is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 radiation 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 parent of an enrollee has requested authorization and coverage for an additional 10 hours per week of ABA therapy (30 hours per week total). Based on the presenting information, ABA treatment guidelines developed by the Council of Autism Service Providers (CASP) and the ABA Coding Coalition, and the medical necessity criteria by Papatola and Lustig, an additional 10 hours per week of ABA therapy (30 hours per week total) are not medically necessary for treatment of this patient. The CASP and the ABA Coding Coalition both highlight the required components of ABA service provision. This includes assessment, goal setting, supervision, service intensity, and discharge elements. The ABA Coding Coalition indicates that treatment recommendations are based on a comprehensive assessment to develop an individualized treatment plan based on the patients direct observable data. Further, the CASP specifies that, Treatment may vary in terms of intensity and duration, the complexity and range of treatment goals, and the extent of direct treatment provided. Many variables, including the number, complexity, and intensity of behavioral targets and the clients own response to treatment help determine which model is most appropriate. Given this patients multiple authorization requests, the number of goals being addressed during treatment, and the patients positive response to treatment, the dosage of 20 hours recommended by the provider is appropriate. While the parent has requested a higher dosage, there is a lack of supporting documentation that demonstrates that the higher dosage is medically necessary. In addition, an additional 10 hours per week of ABA therapy (30 hours per week total) does not meet the medical necessity criteria outlined by Papatola and Lustig. The records document that the patient has made more progress with 20 hours in the previous authorization than at 30 hours during the initial authorization. Moreover, an additional 10 hours per week of ABA therapy (30 hours per week total) is not in accordance with the generally accepted standards of mental health and substance use disorder care or clinically appropriate in terms of frequency, extent, and duration. For these reasons, an additional 10 hours per week of ABA therapy (30 hours per week total) are 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The parents of an enrollee have requested reimbursement for Super Food Panel Allergy Testing provided on 6/15/20 by Foundation Labs.Findings: Three out of three physician reviewers found that the Super Food Panel Allergy Testing provided on 6/15/20 by Foundation Labs were not likely to have been more beneficial for the enrollee than any available standard therapy.Bernstein and colleagues state that testing for the most common allergenic foods usually detects most suspected food hypersensitivity, although more tests may be required depending on the clinical situation. Many clinicians test with a limited panel of commonly allergenic foods when food allergy is suspected and there is no clear-cut history of symptoms occurring after exposure to specific foods. The primary tools available to evaluate patients adverse reactions to foods include history (including diet records), physical examination, prick/puncture skin tests, serum tests for food specific IgE antibodies, trial elimination diets, and oral food challenges. The general aims of diagnosis are to determine if food is causing the disorder under evaluation and, if so, to identify specific causal food(s). A proper diagnosis will allow the patient to receive instructions regarding avoidance of problematic food. The current literature and Allergy Practice Parameter Guidelines that address immunoglobin G (IgG) diagnostic testing, which includes IgG food sensitivity and IgG subclass testing, notes that neither of these tests are considered clinically useful, relevant, or a valid method for evaluating for food allergy or food intolerance that may be contributing to an allergic condition. In this case, the medical literature does not support IgG diagnostic testing for the evaluation of this patients food allergy. Therefore, Super Food Panel Allergy Testing provided on 6/15/20 by Foundation Labs was not likely to have been 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 have been more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Adderall sustained release 5 mg daily and increase to 10 mg after one week. Findings:  The physician reviewer found that adults with attention deficit hyperactivity disorder (ADHD) are more frequently presenting for diagnosis and treatment, and that medication is considered as an appropriate treatment. The authors further note that aggregate literature shows that stimulants have a clinically significant beneficial effect in treating ADHD in adults. Santosh and colleagues note that there is some evidence that stimulant medication can improve driving performance in adults with ADHD. The U.S. Food and Drug Administration (FDA) approves the use of Adderall for the treatment of ADHD. Given that current medical literature supports the safety and efficacy of Adderall in the treatment of ADHD, the requested medication regimen is medically indicated. Therefore, Adderall sustained release 5 mg daily and increase to 10 mg after one week is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for vedolizumab infusions in a hospital outpatient facility setting. The submitted medical records do not demonstrate that this patient has experienced a severe or life-threatening reaction with previous infusions of vedolizumab to support an indication for administration of this medication in a hospital outpatient facility setting. The patient is currently stable on vedolizumab. In addition, there is a lack of documentation of a medical condition that renders the patients condition unstable, exceptionally complex, or otherwise unsafe to receive vedolizumab at home or at an outpatient infusion facility (Polinski, et al.; Ostrov, et al.; Bolge, et al.; Huynh, et al.). Specifically, there are no infusion records provided for review stating that the providers in the existing infusion setting have performed special services during infusion, or that an infusion facility has managed any infusion-related complications at the time of administration. Outpatient or home administration of biologic medications such as vedolizumab have been shown to be safe and effective. Moreover, studies have shown high patient satisfaction with the treatment received with home infusion and outpatient infusion facilities. The premedication and monitoring performed before, during, and after vedolizumab administration can also be performed at an outpatient infusion center or at home with appropriate nursing supervision even with access via port rather than peripheral venous access. For these reasons, the requested vedolizumab infusions in a hospital outpatient facility setting are 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 internal medicine with subspecialty 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 proton beam therapy.There is a lack of support for the requested service in this clinical setting. Researchers performed a multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer. The authors compared groups receiving hypofractionated radiation proton therapy and intensity modulated radiation therapy with photons. This analysis found no significant difference in gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, the authors found no difference in disease control between the two modalities. A position statement released by The American Society of Radiation Oncology (ASTRO) stated, Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and intensity-modulated radiation therapy technique. In this case, the patient has been diagnosed with prostate cancer. There is insufficient medical evidence to support proton beam therapy for the treatment of prostate cancer. Therefore, the requested proton beam therapy is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 radiation 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.