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 facial feminization surgeries (reconstruct entire forehead; reconstruction of nose; reduction of facial bones; and suction lipectomy head & neck).Medical literature has stated that facial feminization surgery is medically necessary for some patients and may be a more important treatment for gender dysphoria than genital surgery. This literature has stated that non-genital surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals and that these interventions are not cosmetic or elective or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. Furthermore, Ainsworth and Spiegel have demonstrated that facial feminization surgery, like genital surgery, is associated with improved mental health-related quality of life.In this case, the patient has submitted multiple documents that support her claim that the requested surgeries are medically necessary. A letter from the patients therapist states that the patient has clinically significant distress and functional impairment that could benefit from facial feminization surgery. The patients primary care provider also supports the medical necessity of the requested surgeries to treat the patients gender dysphoria. Under these circumstances, the requested facial feminization surgeries (reconstruct entire forehead; reconstruction of nose; reduction of facial bones; and suction lipectomy head & neck) are 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for Aimovig Autoinjector 70 mg/ml.  The enrollee has a history of migraine headaches, asthma, and hypertension. She has been treated for migraines by her current primary care provider (PCP). She reported headaches a couple of times per week with throbbing and pain up to eight on a scale of one to ten, severe nausea, occasional phonophobia, and occasional aura. Her headaches are disabling and seem to be triggered by stress. She has been treated with different medications including Topamax, amitriptyline, gabapentin, Imitrex, valproic acid, atenolol, Bystolic, magnesium, and Depakote without long term success. She was referred to a neurology center for intractable chronic migraine and underwent Botox injections on three different dates. She reports the Botox did not prevent migraines. On a visit with her PCP, it is noted the enrollee gets up to fourteen migraines per month, which are associated with photophobia and phonophobia. The PCP noted multiple medications for prophylaxis (including the amitriptyline, Topamax, gabapentin, Depakote, Botox, and Magnesium) were tried. The record indicates the enrollee was utilizing Imitrex six to seven times per month.  She has been on multiple prophylactic medications, including amitriptyline, Topamax, gabapentin, Depakote and Botox.  The enrollee had also tried magnesium. According to the current peer-reviewed medical literature, Aimovig is FDA-approved as a calcitonin gene-related peptide receptor antagonist indicated for the preventive treatment of migraine in adults.  After review of all of the provided documentation, the information substantiates the enrollee has a diagnosis of migraine headaches.  She has tried and failed multiple other medications including amitriptyline, Topamax, gabapentin, Depakote, Botox, magnesium, Valproic Acid, Bystolic, and atenolol.    The enrollee has tried and failed all drug classes that have established efficacy in prevention of migraine headaches. 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 neurology and 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for occipital nerve injections. Findings:  The Physician Reviewer found that the enrollee has a history of occipital neuralgia, low back and neck pain. The enrollee also reported a posterior headache persisting greater than six weeks that had failed to respond to conservative treatment modalities.  Cervical magnetic resonance imaging (MRI) results showed cervical degenerative disc disease and cervical facet arthropathy. The medical literature indicates there is a lack of evidence supporting the use of peripheral nerve blocks in the treatment of primary and secondary headache disorders, with the exception of greater occipital nerve blockade for cluster headaches. Little data exists regarding the efficacy of this treatment; nor are there standardized policies regarding technique, type or dose of local anesthetic. New evidence-based guidelines were published for 26 different interventional pain management procedures; including occipital nerve blocks. The evidence indicated low performance for occipital nerve blocks.  There is no evidence to support the use of greater occipital nerve blocks and no significant evidence to support this is a standard of care. Existing studies regarding the use of greater occipital nerve blocks show equivocal results; currently, no guidelines exist for the use of this technique in the management of headaches. Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: The three reviewers are board certified in Pain Management and are actively practicing.  All three 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

The patient is a 34-year-old transgender female who was diagnosed with gender dysphoria. The patients provider noted the patient had symptoms of chronic anxiety and depression due to her body not aligning with her identity. The records noted that the patient was being treated with hormone therapy. The patient has requested authorization and coverage for any or all facial feminization surgeries. At issue in this patients case is whether any or all facial feminization surgeries are medically necessary for treatment of the patients medical condition. The current medical evidence supports the requested services in this clinical setting. In this case, the records document gender dysphoria. Researchers reported that surgical treatment of transgender patients is associated with improved mental health-related quality of life. The World Professional Association of Transgender Health states that facial feminization surgery and reconstructive procedures are medically necessary for the treatment of gender dysphoria. Therefore, any or all facial feminization surgeries 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 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 enrollee is requesting authorization and coverage for Ensure Complete Liquid. She has a history of bipolar disorder, anxiety, fibromyalgia, chronic bronchitis, obstructive sleep apnea, gastritis, gastroesophageal reflux disease (GERD), peptic ulcer, morbid obesity, and irritable bowel syndrome (IBS). She has a long history of gastrointestinal symptoms and has been taking Ensure Liquid. She was seen by her physician for diarrhea and stool studies were ordered for gastroenteritis. Her physician noted multiple Emergency Department (ED) visits in the last few weeks for ongoing diarrhea and nausea. Her abdomen was soft, and distended with hyperactive bowel signs, and diffuse tenderness to palpation. She reported she was drinking Ensure. A computed tomography (CT) scan indicates the patient had constipation; likely due to polypharmacy. She was seen in the ED again for abdominal cramping and diarrhea. Toradol, Imodium, Zofran, and Tylenol were prescribed. At a follow-up visit, she indicated she had nausea and could not eat any solids. Her body mass index (BMI) was 30.84. She requested an Ensure refill prescription, which the physician declined as she had been witnessed eating a sandwich without difficulty. The medical literature discusses adult body mass index (BMI). A normal BMI is 18.5  24.9. A BMI over 30 is considered obese. This patient had a BMI over 30. With this BMI, additional caloric supplementation is not required. There is insufficient evidence in the medical record of history of severe weight loss or malnutrition in this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in internal medicine and 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 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 modafinil 200 mg 45 tablets.Medical literature indicates that modafinil may be an effective alternative to stimulants in the treatment of hypersomnia in patients with bipolar disorder. A study conducted by Frye and colleagues concluded that adjunctive modafinil at doses of 100-200 mg a day may improve depressive symptoms in patients with bipolar disorder.In this case, the submitted medical records indicate that the patient has had hypersomnia for years. She is noted to have struggled with this condition and has seen many specialists in order to maximize her medication treatment for this condition. Medical recommendations include continuation of modafinil, and the literature supports use of the medication for bipolar disorder as well as hypersomnia. It appears that the patient has significant functional problems due to her hypersomnia as well as her bipolar disorder, as referenced by her use of the antipsychotic medication Seroquel, which was noted to cause sedation for the patient. It does not appear that she has had complete resolution of her hypersomnia with any treatment other than modafinil. The patients current use of modafinil appears to be working fairly well for her, and discontinuation could have significant adverse results. Under these circumstances, modafinil 200 mg 45 tablets 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 patient has requested authorization and coverage for implant nerve stimulator surgery. Craniofacial pain is difficult to treat and can have severe implications for patients with this condition. Craniofacial pain includes trigeminal neuralgia, trigeminal neuropathic pain, and persistent idiopathic facial pain. This patient presents with craniofacial pain. The patients provider has recommended treatment with an implanted nerve stimulator. Early results are promising and neurostimulators have demonstrated efficacy in small patient cohorts with a variety of craniofacial pain states. This patient sustained a left orbital blowout fracture and he presents with left-sided facial pain. All told, the requested implant nerve stimulator surgery is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested surgery 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 neurological 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The parent of the enrollee requested authorization and coverage for deep brain stimulation (DBS) surgery. The enrollee has a history of encephalomyelitis, left basal ganglia infarct, seizures, and right-sided dystonia. The neurosurgeon indicates the enrollee would be a good candidate for DBS surgery.  Treatment for dystonia includes Botox and Baclofen with variable outcomes. Due to the enrollee's lack of significant response to these treatments, deep brain stimulator (DBS) is a treatment option. The medical literature indicates children with functionally debilitating, medication-resistant secondary dystonia, without fixed skeletal deformities, can benefit most from this procedure.  Because of the variability and limited studies in pediatric dystonia, there are no current consensus treatment guidelines. However, patients that do respond to DBS exhibit significant improvement in quality of life regardless of the underlying cause.  The utilization of deep brain stimulation in children is relatively rare, but the procedure demonstrates a reduction in motor symptoms and disability in pediatric patients with dystonia.  Patients respond better to DBS than to medications and the procedure can have benefits for those who have proven refractory to Botox treatment.  Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: One reviewer is board certified in pediatric neurology and neurodevelopmental disabilities, two reviewers are board certified in neurosurgery and are actively practicing.  All three 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 Testopel pellets every six months. This patient has a history of hypogonadism. He has been treated with testosterone pellets, and his provider has monitored the patients testosterone levels. He has maintained mid normal testosterone levels with this therapy, with no adverse side effects. The Endocrine Society guidelines recommend testosterone therapy for men with symptomatic testosterone deficiency to induce and maintain secondary sex characteristics and correct symptoms of hypogonadism after discussing the potential benefits and risks of therapy. Testosterone pellets are a form of testosterone replacement therapy. The patients provider has been properly monitoring the efficacy and safety of this therapy. The current medical evidence supports the requested medication in this clinical setting. Therefore, Testopel pellets every six months are 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The parent of the enrollee is requesting authorization and coverage for speech therapy. The enrollee was screened for developmental problems. An assessment showed a mild delay in expressive language and a moderate delay in receptive language. The enrollee has been receiving speech therapy and is making progress. Documentation also states he is showing increased engagement. According to the medical literature, a diagnosis of developmental deficit in a child indicates an abnormal state of function, and speech, language, and hearing services are as medically necessary for this enrollee as they are for an adult who has suffered a stroke and has lost speech and language function. Speech language therapy is the best method to treat developmental expressive language disorder. The goal of speech therapy is to increase the number of phrases a child can use. Based on the improvement noted by his speech therapist and the active involvement of the enrollees family in his therapy efforts, speech therapy two times per week is medically necessary. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pediatric rehabilitation 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The parent of the enrollee is requesting reimbursement for Intensive Outpatient (IOP) services. The enrollee was admitted to a residential treatment center due to a history of weight loss, panic attacks and suicide attempts. His diagnoses upon admission were anorexia nervosa, binge/purge type; major depressive disorder, and generalized anxiety disorder. He was admitted to a residential treatment program, followed by a partial hospitalization program. He stepped down to intensive outpatient program (IOP) services. In IOP, the enrollee received individual therapy, group therapy, and family sessions. He was discharged from the IOP program with plans for relapse prevention and outpatient follow up. The health plan denied the requested services as not medically necessary. Review of the record, applying guidelines, indicates the following.  Guidelines indicate the requested level of care is generally appropriate for children and adolescents who need more intensive outpatient treatment and are either living with their families with support, or in alternative families, or group facilities, in the community and who have a composite score of 14-16. The enrollee's score was 16.   Final Result: The reviewer determined that the requested service was medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for gene test. She found a palpable mass in her left breast.  A lesion and two other areas of microcalcifications were found on mammography. A biopsy showed ductal carcinoma in situ of the left breast. The enrollee has a family history of pancreatic cancer. Her OB/GYN and breast surgeon recommended genetic testing for BRCA genes and genetic counseling. The gene testing was performed. This was negative with no clinically significant mutation identified. The enrollee subsequently underwent a double mastectomy. Her post-surgical diagnosis was anatomic stage 2B, prognostic stage 1B breast cancer that is estrogen receptor and progesterone receptor positive, HER-2/neu negative, with left axilla sentinel node involvement. She was seen for genetic counseling. The enrollee meets guidelines for genetic testing. She is a young woman with infiltrating ductal cancer and node-positive disease.  The guidelines also indicate it is appropriate for this testing to be ordered by an OB/GYN, breast surgeon or genetic counselor. Complex or high-level genetic testing may be appropriate for certain patients due to family or personal history, or due to the presentation and the diagnostic results of the patient. Multigene assays are a way to personalize systemic adjuvant therapy choices as the available assays have strong prognostic capability. Identifying mutations in either the BRCA1 or BRCA2 genes in a woman with breast cancer can influence her immediate and long-term management decisions regarding systemic therapy and early investigation in the treatment trajectory can most influence cancer care. Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in general surgery and are actively practicing.  All three 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.