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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast reconstruction revision/exchange bilateral breast implants for treatment of the enrollees congenital marked asymmetry of the breasts and reconstructive in nature. Findings:  The physician reviewer found that congenital breast deformity is a well-recognized condition that may be amenable to breast reconstruction. In this patients case, she has a painful capsular contracture that can be considered a complication of her original reconstructive surgeries. Thus, the proposed surgery is considered medically necessary to treat a functional impairment. Further, as stated by the American Society of Plastic Surgeons (ASPS), attempts at correction of these deformities should be considered reconstructive surgery. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Based on the medical documentation provided for this review, the patient has a congenital breast deformity that required right breast reconstruction with an implant initially, followed by bilateral reconstruction that included a contralateral mastopexy. This patients original surgery was reconstructive as it was performed in order to correct a congenital deformity. Based on the most recent documentation, the patient has moderate deformity and symptomatic capsular contracture. This would be considered abnormal appearing breasts. She presents with a painful capsular contracture which is a complication of her original reconstructive surgeries. Thus, any correction of a complication as a result of reconstructive surgery should be considered reconstructive as well. Therefore, attempts to approximate a more normal appearance should be considered reconstructive and not cosmetic. Further, the proposed surgery is likely to result in more than a minimal improvement in the appearance of the patient. For these reasons, the requested breast reconstruction revision/exchange bilateral breast implants is supported as medically necessary for treatment of this patients congenital breast deformity and reconstructive in nature. Final Result: The reviewer determined that the requested surgery is medically necessary for treatment of the patients medical condition and reconstructive in nature. Therefore, the Health Plans denial should be overturned.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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested coverage for Humatrope for treatment of the enrollee's growth hormone deficiency. Findings:  The physician reviewer has found the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The patient meets criteria for growth hormone deficiency, as her height is less than the third percentile for age, her bone age is delayed, her growth velocity is poor, and she has had a poor peak growth hormone response to stimulation testing. However, there is no difference in efficacy or adverse effect profile between various growth hormone products. Thus, there is no medical necessity for use of Humatrope brand name. Nutropin AQ is a satisfactory treatment for this patients diagnosis. There is no documentation that the patient had an adverse reaction to or cannot tolerate Nutropin AQ.  All told, Humatrope is not medically necessary for the 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for AndroGel gel packet for treatment of the enrollees hypogonadism. Findings: The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. Fatigue, lack of concentration, reduced muscle and bone mass, and weight gain are symptoms of male hypogonadism. Abadilla, and Dobs in their review of topical testosterone supplementation for treatment of male hypogonadism noted, Topical/transdermal testosterone replacement therapy, including patches and gels, are the most modern formulations on the market. These treatment options have been known to yield more physiological concentrations of testosterone. Restoration of testosterone levels to the eugonadal range reverses signs and symptoms of hypogonadism, except for infertility, and may alleviate co-morbidities associated with hypogonadism. In determining best treatment options for patients, Shoskes and colleagues noted the following, The decision on the best product choice should include patient preference, PKs, treatment burden, cost and insurance coverage. Products may also need to be switched throughout TRT based upon patient response, preference, and adverse effects. In all circumstances, the decisions should be an open dialogue between the patient and clinician to allow for the most successful TRT regimen. In patients case, he was noted as doing well clinically and was stable with the AndroGel brand preparation. He tried the generic version, with poor response and lack of absorption. The provider has prescribed AndroGel for effective therapy. This patient had an adverse effect to the generic testosterone gel. The generic testosterone gel did not work because it was not absorbed properly in this patient. As such, replacement of testosterone with AndroGel gel packet is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 the FoundationOne gene test performed for evaluation of the enrollees moderately differentiated adenocarcinoma.Findings: The physician reviewer has found that FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers than can help guide therapy decision making. Per the National Comprehensive Cancer Network (NCCN) guidelines, it has not been determined if molecular markers are useful in treatment decisions and prognosis other than KRAS, NRAS, and BRAF mutations. FoundationOne is the subject of an ongoing phase II trial. All told, there is a lack of peer-reviewed medical literature demonstrating that the FoundationOne testing performed was likely to be more beneficial for evaluation of this patients adenocarcinoma than any available standard testing. Final Result: All three physician reviewers determined that the testing at issue was 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prostate surgery, prostatic urethral lift implant for  treatment of his benign prostatic hyperplasia.Findings:  Three physician reviewers found that the current medical evidence supports the requested services in this clinical setting. The recommended procedure is a novel, minimally invasive approach to treating benign prostatic hyperplasia that lifts or holds the enlarged prostate tissue out of the way so it no longer blocks the urethra. Recent clinical trials, including prospective, sham controlled, randomized studies, have shown that the UroLift system is safe and effective in relieving lower urinary tract symptoms due to benign prostatic hyperplasia without significantly compromising sexual function.  Compared with transurethral resection of the prostate and photoselective vaporization of the prostate, the UroLift system is minimally invasive procedure without a requirement of general anesthesia and with a potentially shorter operative time.  All told, the requested prostate surgery, prostatic urethral lift implant is likely to be more efficacious than other treatment options. Final Result: All three 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: Three physician reviewers are  board certified in urology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cooled radiofrequency denervation for treatment of the enrollees low back pain. Findings: Three physician reviewers found that Lumbar medial branch radiofrequency ablation or neurolysis is a well-documented procedure which helps with chronic low back pain due to lumbar facet pain. Son and colleagues noted that repeated radiofrequency ablation for lumbar facet syndrome does provide successful pain relief for about 10 months in more than 85% of carefully selected patients. The procedure is successful in treating lumbar spine pain in repeated fashion. However, there is not significant literature for the use of cooled radiofrequency denervation.  While there is support for lumbar radiofrequency ablation using traditional technique, the superior effectiveness of the requested cooled radiofrequency denervation has not been established.Final Result: The reviewers determined that the requested services 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: All three physician reviewers 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic laboratory testing provided for evaluation of the enrollees cutaneous melanoma. Findings: The physician reviewer has found that the DecisionDx melanoma assay tests the tissue genetics of the melanoma to help stratify whether a thin melanoma is high risk for metastasis. The DecisionDx test has shown some impressive accuracy in thin melanomas like this patients tumor. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Further, DecisionDx testing is not supported for patients with intermediate thickness melanoma tumors. All told, the genetic laboratory testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three physician reviewers determined that the testing at issue was 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: All three physician reviewers 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) services for treatment of the enrollees depression and anxiety. Findings:  The physician reviewer found that as noted in the current medical literature, TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. The procedure is approved by the U.S. Food and Drug Administration (FDA) and tends to be very well tolerated with fewer barriers than electroconvulsive therapy. Further, the American Psychiatric Association (APA), investigated TMS and the available literature and concluded that TMS is appropriate for patients in the acute phase of treatment of major depressive disorder after failure of at least one antidepressant trial. Although this patient has had prior episodes of depression, the records do not describe any treatment for the most recent depressive episode prior. At that time, he was anxious and depressed with a constricted affect. He was started on sertraline, which is a selective serotonin reuptake inhibitor (SSRI) FDA approved for the treatment of major depressive disorder. The SSRIs are first-line medications for both depression and anxiety, and have a reassuring safety profile. However, they can take up to 12 weeks to reach maximal effect. Although sertraline is typically dosed between 100 and 200 mg daily, the patient showed signs of clinical improvement within four weeks from starting the medication. The patient was described as euthymic with logical thought processing and an appropriate affect in the absence of suicidality. Both the relatively conservative dose of 50 mg daily and prompt clinical response represented significant favorable prognostic indicators for the pharmacotherapeutic intervention. In sum, the documentation does not demonstrate failure of at least one anti-depressant medication during the episode of illness. Thus, based on current practice parameters, TMS services are not medically necessary. 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 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 weekly mental health therapy visits for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that there is no defined frequency or duration for the amount of psychotherapy required for each patient. However, it is generally accepted that patients in crisis require more frequent sessions than patients who are stable. The medical literature also supports that in unrestricted therapies, each additional psychotherapy session has a diminished effect.  Given this information, the patient has had extensive mental health treatment in the past. The patient starting seeing a non-Plan psychotherapist. Per the documentation, the patient reported in an email that the non-Plan provider cannot see the need for weekly sessions. Based on the submitted documentation, the patient was stable. He has been sober for over six months. He did not have any suicidal ideation or homicidal ideation. The patient was working, sleeping well, and had improvement from his psychotherapy sessions. The records do not demonstrate that the patient requires weekly psychotherapy sessions. All told, weekly mental health therapy visits are not medically necessary for the 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 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: The enrollee requested requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation (TMS) for treatment of the enrollees behavioral health condition. Findings: Three physician reviewers found that there is ample support in the medical literature and in the documentation provided for the efficacy of TMS in this patients case. The patients history outlines treatment resistant major depressive disorder. Whether or not there were underlying bipolar II issues, this patient has a longstanding major depressive illness which has been essentially unresponsive to multiple medication trials (greater than the four), or has suffered from side effects, and was fearful of ECT/anesthesia. However, the records reflect that she has shown a robust response to the TMS treatments she received, and has been medically stable.  For these reasons, TMS past treatments and forward were and are likely to have been more effective than the standard options available for treatment of this patients medical condition. Final Result: The reviewers determined that the services at issue were and 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: All three physician reviewers are board certified in psychiatry and are actively practicing. The reviewer 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene expression profiling test for evaluation of the enrollees uveal melanoma. Findings: Three physician reviewers found that this patient has a rare disease, ocular melanoma. The Collaborative Ocular Melanoma Study Group Report No. 26 by Diener-West and colleagues demonstrated equivalent survival in patients treated with brachytherapy versus enucleation. Knowledge of the propensity for metastasis directly affects surveillance of patients by computed tomography scan. Along these lines, clinical studies have been done using the gene expression classifier DecisionDX UM, which defines two classes of ocular melanoma. Class I is associated with a low risk of metastasis and class 2 has a 50% risk at two years and 72% risk at five years. This gene expression classifier is discussed in the Physicians Data Query of the National Cancer Institute. There is very limited standard prognostic indicator that could serve as an alternative for evaluating this rare ocular melanoma. Thus, the current medical evidence favors the use of this genetic testing in the postoperative surveillance of patients diagnosed with ocular melanoma. For these reasons, the gene test (gene expression profiling) performed was likely to be more beneficial than any other available methods in the evaluation of this patient.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. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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.