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 facial feminization surgery, a tracheal chondroplasty/tracheal shave. Findings:  The physician reviewer found that World Professional Association for Transgender Health (WPATH) lists facial feminization surgery as a medically necessary treatment for gender dysphoria. WPATH notes that for certain patients, surgical procedures such as facial feminization surgery can have a radical and permanent effect on their quality of life. In this case, given that the patient has a diagnosis of gender dysphoria and the provider has recommended facial feminization surgery, the requested services are medically indicated. Therefore, facial feminization surgery, a tracheal chondroplasty/tracheal shave, is medically necessary for the treatment of this patient.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 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: The patient has requested authorization and coverage for venlafaxine 37.5 mg immediate-release tablets (60 tablets with two refills). The U.S. Food and Drug Administration (FDA) notes that venlafaxine extended-release (brand name Effexor XR) is included in a class of medications called serotonin and norepinephrine reuptake inhibitors (SNRIs) and approves its use for the treatment of major treatment disorder, generalized anxiety disorder, social anxiety disorder, and panic disorder. Stahl and colleagues note, Venlafaxine is available as an extended-release formulation (venlafaxine XR), which not only allows for once-daily administration, but also significantly reduces side effects, especially nausea. In contrast to several other psychotropic drugs available in controlled-release formulations, venlafaxine XR is a considerable improvement over the immediate-release formulation. The immediate-release formulation of venlafaxine has actually fallen into little or no use because of unacceptable nausea and other side effects associated with this formulation, especially when venlafaxine immediate-release is started or when it is stopped. However, venlafaxine even in controlled-release formulation can cause withdrawal reactions, sometimes quite bothersome, especially after sudden discontinuation from high-dose, long-term treatment. Nevertheless, the controlled-release formulation is highly preferred because of enhanced tolerability. In general, physicians prescribe the extended-release formulation of venlafaxine due to a higher rate of moderate-to-severe discontinuation symptoms with the use of the immediate-release formulation of the medication, including dysphoria, headaches, nausea, irritability, emotional lability, sensation of electric shocks, and sleep disturbance. Medication compliance rates with the extended-release formulation, which only requires one dose daily, tend to be higher than with the immediate-release formulation, which may require two to three doses daily. The extended-release formulation is also associated with less nausea and dizziness at the initiation of therapy as compared to the immediate-release formulation. In this case, the records do not indicate that the patient has been trialed on venlafaxine ER, any of the other SNRIs, or any selective serotonin reuptake inhibitor antidepressants (SSRIs). Therefore, venlafaxine 37.5 mg immediate-release tablets (60 tablets with two refills) are 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 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 enrollees parent has requested reimbursement for wilderness therapy at Evoke Second Nature Entrada. Current medical literature suggests that wilderness therapy may be an effective treatment option for a wide variety of adolescents, including youth with substance abuse problems and adolescents suffering from depression and various other clinical disorders, and improve interpersonal relationships. However, there is a lack of evidence supporting the claim that outdoor behavioral healthcare programs are superior to standard therapies as a treatment intervention for adolescent substance use and mental health disorders. Few studies directly compare outcomes of outdoor behavioral healthcare programs to other therapeutic interventions. Dobud and Harper note that in a scoping review of direct comparison trials in adventure therapy, only 13 studies met the full inclusion criteria. The authors found few significant differences to isolate specific therapeutic factors. While literature on outdoor behavioral healthcare programs suggest that participants show some level of improvement on behavioral health outcomes, the results are not conclusive and there is a lack of randomized controlled trials or well-designed cohort studies that would allow for causal conclusions about the impact of outdoor behavioral healthcare programs. In this clinical setting, there is a lack of data to support the claim that outdoor behavioral healthcare programs were more effective than other therapies. Therefore, wilderness therapy at Evoke Second Nature Entrada was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the wilderness therapy at Evoke Second Nature Entrada at issue was not likely to have been 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 reviewers 1, 2, and 3 are board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any residential treatment center (RTC) services. Per American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient underwent management for alcohol withdrawal. The patients withdrawal needs were safely managed in a level 3.5 setting. For dimension 2, the patient did not have biomedical conditions and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient reported symptoms of depression and social anxiety. The patient endorsed suicidal ideation, with a history of a suicide attempt via overdose. The patient reported using substances to function, and the records noted that the patient was experiencing night terrors. The patients mental status was stable enough to permit participation. He demonstrated a repeated inability to control his impulses to use alcohol, and he was in imminent danger of relapse with attendant likelihood of harm to self. For dimension 4, the patient was admitted voluntarily for treatment, reporting that he was tired of his substance use and of not being able to function. The patient reported feeling depressed with suicidal thoughts due to hopelessness about his addiction. He had been using substances despite being in outpatient treatment. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions had not succeeded at less intensive levels of care. For dimension 5, the patient relapsed despite being in an outpatient program following five months of sobriety. He had a history of one prior suicide attempt and reported suicidal thoughts and feelings of hopelessness. Despite recent, active, participation in treatment at a less intensive level of care, the patient continued to use drugs with imminent serious consequences and was at high risk of continued substance use in the absence of close 24-hour monitoring and structured treatment.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections in both axilla every three months. The authors reported that, Antiperspirants are regarded as the first-line therapy for primary focal hyperhidrosis and can provide significant benefit. Additionally, the authors endorsed Botox injections as a safe and effective treatment option for focal hyperhidrosis. This patient presents with severe axillary hyperhidrosis that has failed to improve with conservative treatment including first-line antiperspirants. Treatment with Botox dosed every six months has been beneficial. However, the patients provider documented complaints of recurrence of symptoms in the interim between injections. In this clinical setting, an increase in frequency to every three months is appropriate and consistent with the peer-reviewed medical literature recommendations. Therefore, the requested Botox injections in both axilla every three months are 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 requested Botox injections in both axilla every three months are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom foot orthotics. Findings:  The physician reviewer found that Pes planus, by its nature, does not always cause pain. Further, Banwell and colleagues state, No high level evidence supports the use of foot orthoses for flexible pes planus. In this case, the patient has been diagnosed with congenital pes planus and strain of unspecified muscle and tendon at ankle and foot level. According to the medical literature, the use of orthoses is not supported in patients with pes planus alone. Moreover, the diagnosis of strain of unspecified muscle and tendon at the ankle and foot level right foot does not necessitate orthotic treatment.  In order to establish the medical necessity of the requested equipment, a more extensive physical examination and a more definitive diagnosis are needed. Therefore, the requested custom foot orthotics are not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment 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 podiatry 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 genetic laboratory testing. Generally, patients with venous thromboembolism (VTE) with at least one first degree relative with documented VTE before a certain age should be tested for the presence of all five inherited thrombophilia. Bhatt and colleagues note that factor V Leiden, along with factor II genetic testing, remains an important testing option in VTE. In visit notes, the patient reported a diagnosis of deep vein thrombosis (DVT), and that a family member was affected by DVT. In this clinical setting, identification of a factor V Leiden variant is unlikely to change management of the patients course. Therefore, genetic laboratory testing was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 and 2 are board certified in internal medicine with sub-specialty certifications in medical oncology and hematology and are 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 any or all of the lipedema surgeries (stage 1: bilateral lower extremity posterior, CPT code 15879 modifiers --22, --50 RT/LT, lipedema reduction surgery trunk CPT code 15877-22; stage 2: bilateral lower extremity anterior, CPT code 15879 modifiers --22, --50 RT/LT; stage 3: bilateral upper arms, CPT code 15878-22-50 RT/LT and/or stage 4: excision excessive skin/subcutaneous tissue CPT code 15832-22-50 RT/LT). Buso and colleagues note that weight loss measures exhibit minimal effect on the abnormal fat distribution that characterizes lipedema. For the treatment of lipedema, Dadras and colleagues note that liposuction is an effective surgical option. Wollina and Heining note that micro-cannular liposuction in tumescent anesthesia is an effective treatment for painful lipedema and that the procedure should be performed in specialized centers. Schmeller and colleagues report that tumescent liposuction is a highly effective treatment for lipedema with good morphological and functional long-term results. Baumgartner and colleagues found in a single-center study of 85 patients with lipedema that beneficial results from liposuction surgery persisted eight years after treatment. In this case, the patient has lost over 200 pounds with diet and exercise. The remaining adipose/weight in her thighs and buttocks is consistent with a diagnosis of lipedema. She has tried and failed conservative measures such as diet, exercise, compression garments, manual lymphatic drainage, pneumatic compression pump, and multiple medications including Cymbalta. Photographs of the patient suggest type II lipedema, showing disproportionate adipose distribution in the bilateral hips, buttocks, and thighs with relative sparing of the arms, lower legs, and feet. In this clinical setting, lipedema reduction surgery to treat the patients trunk and lower extremities, excluding the arms, is medically indicated. Therefore, lipedema surgeries (stage 1: bilateral lower extremity posterior, CPT code 15879 modifiers --22, --50 RT/LT, lipedema reduction surgery trunk CPT code 15877-22; stage 2: bilateral lower extremity anterior, CPT code 15879 modifiers --22, --50 RT/LT; and stage 4: excision excessive skin/subcutaneous tissue CPT code 15832-22-50 RT/LT) are medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in vascular 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 laboratory testing (CPT codes 86001, 88184, and 88185). Hammond and colleagues note that the gold standard for diagnosis of immunoglobulin E (IgE)-mediated food allergy remains the oral food challenge, with serum IgE testing and skin prick testing serving as acceptable alternatives. The authors further note that alternative diagnostic procedures, including IgG testing, electrodermal testing, cytotoxic testing, provocation/neutralization, and applied kinesiology, for suspected food allergies have largely been unproven and may lead to unnecessary elimination diets. In this clinical setting, immunoassays have a high positive predictive accuracy in children for several of the major food allergens. Therefore, laboratory testing (CPT codes 86001, 88184, and 88185) is not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested laboratory testing (CPT codes 86001, 88184, and 88185) is 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 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 reviewer 1 is board certified in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in internal medicine and allergy and  immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology and pediatrics 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epidiolex 100 mg/mL solution. Cannabidiol was reported to improve psychosis in patients with schizophrenia in two randomized controlled clinical trials (McGuire, et al.; Black, et al.). However, there is a paucity of data demonstrating that cannabidiol is effective in the treatment of patients with bipolar disorder. This patients records support a diagnosis of bipolar disorder. In addition, there are well established algorithms for to direct the treatment of bipolar mania, which currently do not recommend the use of cannabidiol in for bipolar mania or anxiety (Stovall, et al.). Moreover, the medical literature does not recommend the use of cannabidiol for bipolar mania or anxiety due to the lack of evidence (Black, et al.). In this clinical setting, the requested Epidiolex is not likely to provide this patient with a superior health outcome when compared to treatment with conventional options. All told, the requested Epidiolex 100 mg/mL solution is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the Epidiolex 100 mg/mL solution is not likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy. Final Result: The reviewers determined that the requested medication 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 psychiatry and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeomin (incobotulinumtoxin A) injections. Findings: Cervical dystonia is a movement disorder clinically characterized by involuntary contractions of cervical muscles, which cause abnormal head movements and postures, often associated with head tremor and chronic pain. Classifications of cervical dystonia include torticollis, laterocollis, anterocollis, and retrocollis or a combination of these movements. Per the American Academy of Neurology (AAN) practice guidelines, Xeomin  is recommended as first-line treatment for cervical dystonia. The U.S. Food and Drug Administration (FDA) has approved Xeomin for the treatment of cervical dystonia. Per the AAN guidelines, Xeomin and onabotulinumtoxinA should be considered as options for the treatment of cervical dystonia. In this case, the patient has cervical dystonia with spasmodic torticollis. The patient has reportedly failed treatment with methocarbamol, Baclofen, Carisoprodol, and cyclobenzaprine. However, the patient experienced symptomatic improvement with Xeomin. Given these findings, the requested Xeomin (incobotulinumtoxinA) injections 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 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.