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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for isotretinoin capsules.Autosomal recessive congenital ichthyosis (ARCI) is a heterogeneous group of nonsyndromic disorders of keratinization, which includes lamellar ichthyosis (LI), congenital ichthyosiform erythroderma (CIE), and harlequin ichthyosis (HI). In addition to cosmetic problems, ichthyosis patients usually suffer from a series of medical problems that are directly or indirectly related to pathomechanisms which are also potential targets for therapy. The symptoms include: pruritus, painful fissuring of the thickened skin, decreased range of motion at joints, decreased tactile sensitivity especially of the fingers, hypohidrosis with heat intolerance, a liability to skin irritation, and, in some cases, an increased tendency to skin infection. The range and severity of symptoms usually vary considerably from one patient to another and may also change over time in one and the same patient. This makes it essential always to adjust therapy according to the patients individual and current needs.Symptomatic treatment with emollients and topical keratolytics remains the mainstay therapy for ichthyosis, and should be maintained also when adjuvant systemic agents are prescribed. Glycerol, urea, and propylene glycol are the most commonly used hydrating ingredients, usually in cream formulations. Three important mechanisms are involved in the action of topical agents used in the treatment of ichthyosis: hydration, lubrication and keratolysis. The latter effect can also be achieved with systemic retinoids. Retinoids have keratolytic effects that facilitate the shedding of scales from the surface and prevent excessive hyperkeratosis, thus leading to a more normal thickness and improved function of the horny layer.In this case, the patient has been diagnosed with autosomal recessive congenital ichthyosis. The medical literature supports the use of systemic retinoids such as isotretinoin for their keratolytic effect in the treatment of ichthyosis. The patient has been on isotretinoin and the medication has already shown high clinical efficacy. Under these circumstances, isotretinoin capsules are medically necessary for treatment of the 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 dermatology 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 the medication Xanax/Xanax XR. The submitted documentation reflects that the patient has panic disorder that is having a major impact on her quality of life and affecting her mood and anxiety. Records also reflect that the patient is in sustained, full remission from opioid use disorder. The medical literature does not support that Xanax is contraindicated for the treatment of panic disorder in patients who are in sustained, full remission from opioid use disorder. Under these circumstances, the requested medication Xanax/Xanax XR is medically necessary for treatment of the 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for double mastectomy with masculinization reconstruction.The World Professional Association for Transgender Health (WPATH), a worldwide authority on transgender health issues, has stated that chest surgery may be carried out earlier than age 18, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. WPATH Standards of Care state, however, that different approaches may be more suitable, depending on an adolescent's specific clinical situation and their goals for gender identity expression. The WPATH reference to one year on testosterone is not an absolute requirement, but is dependent on an adolescent's specific clinical situation. Since the publication of WPATH Standards of Care Version 7, there has been substantial experience by clinicians in the provision of chest surgery for transmasculine youth. Researchers conducted a cohort study that demonstrated the efficacy of chest surgery in relieving distress in transmasculine youth. The study concluded that chest dysphoria was high among presurgical transmasculine youth, and that surgical intervention positively affected both minors and young adults. The study concluded that transmasculine minors should be referred for chest surgery based on individual need rather than chronological age.In this case, the patient has a documented history of gender dysphoria, he has been on puberty blockers for eight months, and he has been documented to have severe distress due to chest dysphoria. In this specific clinical situation, the severity of the patients distress from chest dysphoria supports chest surgery at this time. Under these circumstances, the requested double mastectomy with masculinization reconstruction is medically necessary to treat the patients medical condition.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for incision for implantation of cranial nerve (CPT code 64568  RT) and insertion of a chest wall respiratory sensor electrode (CPT code 0466T).Findings:  Two of three physician reviewers found that the requested services are likely to be more beneficial than any other available standard treatment for the patients medical condition. Woodson and colleagues performed a multicenter prospective cohort study and concluded that improvements in sleepiness, quality of life, and respiratory outcomes were observed with five years of upper airway stimulation (UAS) via a unilateral hypoglossal nerve implant. Woodson and colleagues noted that serious adverse events were uncommon, and they stated that UAS is a nonanatomic surgical treatment with long-term benefit for individuals with moderate to severe OSA who have failed nasal continuous positive airway pressure treatment. Multiple additional studies indicate that hypoglossal nerve stimulation is a safe and effective treatment option for moderate to severe obstructive sleep apnea patients who have failed medical therapy. Meta-analysis has demonstrated clinically significant decreases in observed mean apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and Epworth sleepiness scale (ESS), combined with improvements in quality-of-life scales. The STAR (Stimulation Treatment for Apnea Reduction) trial also showed that UAS provides significant improvement in sleep-related quality of life outcome measures with effects maintained across a four year follow-up.In this case, the patient has failed CPAP therapy and the severity of his disease makes him a poor candidate for oral appliance therapy. The Inspire Upper Airway Stimulation system has been shown in multiple peer-reviewed studies to be a safe and effective option for treating obstructive sleep apnea. Under these circumstances, incision for implantation of cranial nerve (CPT code 64568  RT) and insertion of a chest wall respiratory sensor electrode (CPT code 0466T) are likely to be more beneficial for treatment of the patients medical condition than any other available standard treatments.Final Result: Two of three reviewers determined that the requested services are likely to be more beneficial than any other available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer 1 is board certified in otolaryngology and is actively practicing. Physician reviewer 2 is board certified in otolaryngology, with subspecialty certification in sleep medicine, and is actively practicing. Physician reviewer 3 is board certified in internal medicine 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: The patient has requested authorization and coverage for the prescription medication Advair Diskus 100-50 mcg. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether the prescription medication Advair Diskus 100-50 mcg is medically necessary for the treatment of the patients medical condition. The U.S. Food and Drug Administration approved a generic version of Advair Diskus (fluticasone propionate and salmeterol inhalation powder) for the treatment of asthma in patients aged four years and older. Ng and colleagues reported, The therapeutic effects of Wixela Inhub are bioequivalent to Advair Diskus in the lung. Wixela Inhub represents a therapeutically equivalent new fluticasone propionate/salmeterol treatment option for use in the treatment of asthma and chronic obstructive pulmonary disease (COPD). In this case, the patient reported new side effects associated with use of the generic version of Advair. Although these medications are therapeutically equivalent, the patient and provider have documented side effects with the use of Wixela Inhub that do not occur with the brand name medication. The medical evidence supports the requested medication in this clinical setting. Therefore, the prescription medication Advair Diskus 100-50 mcg is medically necessary for the 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 family 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Synvisc injections in both knees. The patient has been diagnosed with osteoarthritis of both knees. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. The medical evidence supports the requested services in this clinical setting. Therefore, Synvisc injections 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

An enrollee has requested authorization and coverage for individual mental health therapy, two times a month for the next twelve months. In cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System is indispensable in determining the necessary level of care for adults. The patients composite score is consistent with low intensity community based services. The level of care analysis indicates that meeting two times a month is a reasonable frequency and within the standard of care. Furthermore, the patient is placed at risk for further decompensation, including poor blood sugar control, without treatment of her depression and grief. Under these circumstances, individual mental health therapy, two times a month for the next twelve months, is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for individual therapy services once a week. The enrollee has a history of substance abuse that has worsened over the past years and is impairing his ability to function. The enrollee reports numerous attempts at rehabilitation, including a chemical dependency recovery program, but he believes he has such a strong compulsion to use that he is not able to remain sober longer than 60 days. The patient reports he does not have any available leave of absence time from work and he cannot make it to the chemical dependency recovery program on time. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. The patients composite LOCUS score correlates Level III, High Intensity Community Based Services.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is 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 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 hyaluronic injection to the right knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has tried and failed other conservative treatments with the alternative being surgery. Therefore, whether hyaluronic injection to the right knee 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 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

The patients parent has requested authorization and coverage for Norditropin Flexpro (somatropin) human growth hormone. This patient does not have a known hypothalamic-pituitary defect or deficiency of at least one pituitary hormone other than growth hormone, which would allow the diagnosis of growth hormone deficiency in the absence of growth hormone stimulation testing. In addition, she does not have a medical condition for which growth hormone is recommended. This patient has normal laboratory results, delayed bone age, and her predicted adult height is just a few inches below the mean parental height. Current guidelines support treatment with growth hormone therapy for patients with a height that is two or more standard deviations below the mean for age and gender. In addition, she has normal interval growth. The patients provider has recommended observing her growth over time instead of treating with growth hormone. Given these findings, the requested Norditropin Flexpro (somatropin) human growth hormone is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty 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

An enrollee has requested authorization and coverage for physical therapy visits (50 minutes total treatment time, including 40 minutes of direct contact with the patient, twice a week for 6 weeks). A review of the medical literature reveals that studies to date have not found one exercise regime to be superior to another after a total knee replacement. The literature reveals that physical therapy interventions show short-term improvements in physical function and that there are limited studies that indicate that there are long-term benefits of physiotherapy or exercise interventions after a total knee replacement. The literature does not support that one therapy is more beneficial than another. In this case, the patient has been offered continued physical therapy and she has also been trained in a home exercise program. The documentation and literature do not support that the requested frequency, duration and format of physical therapy (50 minutes total treatment time, including 40 minutes of direct contact with the patient, twice a week for 6 weeks) are medically necessary after total knee replacement. 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 physical medicine and rehabilitation, with subspecialty certification in neuromuscular 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for home speech therapy services. The patient has a demonstrated developmental language disorder. Given the patients age, intervention with a speech pathologist will have significantly more efficacy when the developing brain has more neuroplasticity. Speech and language interventions result in maximal gains during this critical period of neuroplasticity. However, children with developmental language disorder are at significantly greater risk for emotional reactivity. Adding extended travel time to obtain speech and language services is at odds with trying to achieve maximum benefits. Given these findings, the requested home speech therapy services 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 neurology with special qualification in child 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.