Persius/hicric huggingface dataset:
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
 
A 51-year-old female enrollee has requested authorization and coverage for Botox. The Health 
Insurer has denied this request and reported that the requested service is investigational for the 
treatment of the enrollee. The physician reviewer found that standard medical therapies for 
temporomandibular joint disorder include NSAIDs, both enteral and topical, diet restriction, jaw 
exercises including physical therapy, warm and cold compresses, and splinting with a dentist 
prescribed occlusal devise. Gonzalez-Perez and colleagues note that the use of dry needling is 
also becoming more common and has been shown to be safe and effective in the treatment of 
temporomandibular joint disorder. As the use of Botox for the treatment of temporomandibular 
joint disorder is not FDA approved, there is limited high quality data regarding its use and efficacy 
for the treatment of temporomandibular joint disorder, and there is no standardization for its 
administration in this clinical setting. In a randomized controlled trial comparing the efficacy of 
dry needling and Botox in the treatment of temporomandibular joint disorder,  Kutuc and 
colleagues reported that at the end of six weeks, patients treated with dry needling reported 
more pain relief on the visual analog scale (VAS), better improvement in jaw protrusion angles 
on both sides, and better recovery of temporomandibular joint function than the patients treated 
with Botox. In a randomized controlled trial comparing the efficacy of Botox to occlusal splinting 
in the treatment of myofacial pain, Miotto and colleagues noted improvement in both treatment 
arms  but  did  not  specify  any  statistically  significant  difference  between  the  groups.  In  a 
systematic review of the use of Botox in the treatment of temporomandibular joint disorder that 
included an investigation of physical therapy versus Botox, Patel and colleagues found no 
statistically significant difference between either treatment modality. Given the lack of evidence 
supporting the use of Botox over other proven treatment modalities, while Botox is emerging as 
a promising therapeutic option in the management of certain aspects of temporomandibular 
joint disorder, the requested service is not likely to be more beneficial than other currently 
available standard treatments for the treatment of this patient. Therefore, Botox is not likely to 
be more beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a three-year-old male. An assessment dated 3/2/22 reported that the patient did not 
have a history of seizures. The patients parent has requested reimbursement and prospective 
authorization and coverage for private duty nursing, 12-hour days, seven days per week, from 
3/1/22 to 12/31/22. The Health Insurer has denied this request and reported that the services at 
issue were not and are not medically necessary for the treatment of this patient. This denial is the 
subject  of  this  appeal  and  determination.  The  physician  reviewer  found  that  the  submitted 
documentation does not support the medical necessity of the services at issue. Home based nursing 
services are essential for parents of children with life-limiting diseases with basic healthcare needs 
including  personal  hygiene  and  feeding,  the  administration  of  drugs  and  management  of 
symptoms, and pain and sleep related problems during the night. Lazzarin and colleagues report 
that  parents providing palliative care for children with life-limiting diseases spent an average of 
nine hours a day caring for them each day and had to maintain an average of five medical 
appliances. It is important for these families to receive appropriate support with daily care through 
an evaluation of the childs individual needs. Current medical literature shows that the number of 
medical appliances and the status of single caregivers correlate proportionally with a greater 
amount of time needed for a childs care. The data suggests that it is not so much the childs disease 
that determines the daily burden of care for the parents, but the number of different procedures 
that must be expertly managed. In this case, the patient is not dependent on a ventilator, is not 
using a feeding pump or indwelling catheters, and does not have life threatening seizures. Unlike 
children with incurable conditions who are cared for at home and need highly complex medical 
care, this childs quality-of-life may be adequately maintained without 12 hours/day in home 
nursing service. Given that this patient does not have multiple chronic conditions or life-limiting 
diseases that make him dependent on caregivers and the use of complex medical appliances or of 
life sustaining medical devices, the services at issue were not and are not medically indicated. 
Therefore, private duty nursing, 12-hour days, seven days per week, from 3/1/22 to 12/31/22, was 
not and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 49-year-old female with a history of severe non-proliferative diabetic retinopathy 
with macular edema in both eyes. The provider has recommended treatment with Eylea injections, 
which have been shown to slow the progression of retinopathy and will help delay the need for 
surgical vitrectomy. The Health Insurer has denied the requested medication as not medically 
necessary. This denial is the subject of this appeal and determination. The physician reviewer 
found that at the initiation of treatment for her diabetic macular edema, the medical records show 
this patient had corrected visual acuity of 20/40 on the right, and 20/30 on the left side. These 
measurements qualify the patient as having mild loss of visual acuity, given the visual acuity loss 
of 20/40 or better. On review of the current medical literature, Eylea has been shown to have an 
advantage over other anti-VEGF treatments only when a patients presenting vision is 20/50 or 
worse at the start of treatment (Wells, et al.). One study evaluated Eylea monotherapy versus step 
therapy with Avastin followed by a change to Eylea if protocol criteria were met (Jhaveri, et al.). 
The authors noted that the pat in this study had an initial visual acuity of 20/50 or worse. The 
authors concluded that there was a lack of difference in visual acuity outcomes or central retinal 
subfield thickness at the two-year follow-up. Based on this patients presenting mild loss of visual 
acuity and lack of documentation of prior intravitreal injections, the requested Eylea injections 
2/0.05 mL are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a five-year-old male who was admitted for hospitalization for diagnostic evaluation 
and management of the abrupt onset of uncontrolled myoclonic seizures and ataxia. The patients 
parent has requested reimbursement for an inpatient stay from 3/2/22 through 3/5/22. The Health 
Insurer has denied this request and reported that the services at issue were not medically necessary 
for the treatment of this patient. This denial is the subject of this appeal and determination. The 
physician reviewer found that the submitted documentation supports the medical necessity of the 
services at issue. Alix and colleagues note that useful clinical information is obtained in most 
children in whom events are captured on video EEG telemetry. The onset of myoclonic seizures 
in children places them at risk of significant risk of serious injury as the seizures may occur without 
warning and frequently cause the child to fall. The differential diagnosis for myoclonic epilepsy 
in children is broad, ranging from myoclonic-astatic epilepsy to a number of genetic forms of 
progressive myoclonic epilepsy, some of which are eventually fatal. Myoclonic epilepsy can be 
very difficult to control, often requiring high doses of medication, introduction of the ketogenic 
diet, and occasionally the implantation of the vagus nerve stimulator or corpus callosotomy. In this 
case, the patient had an abrupt onset of uncontrolled mixed seizures, with generalized tonic-clonic 
seizures and frequent myoclonic seizures. The patients seizures were frequent and uncontrolled 
despite his being on an Keppra, an anticonvulsant. The records noted that at times the patient had 
multiple myoclonic seizures while on video EEG telemetry. He had also an abrupt onset of ataxia, 
which appeared to have been related to starting Keppra. In this clinical setting, given that an 
inpatient diagnostic workup including a spinal tap, MRI of the brain, and video EEG telemetry to 
capture the seizure type for differential diagnosis, allow assessment of true seizure frequency, and 
assess  response  to  treatment  was  required,  the  services  at  issue  were  medically  indicated. 
Therefore, an inpatient stay from 3/2/22 through 3/5/22 was medically necessary for the treatment 
of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 57-year-old male who presented to his provider on 1/20/22. The patient has 
requested authorization and coverage for MRI cervical spine without contrast material. The 
physician reviewer found that at issue is whether the requested MRI cervical spine without 
contrast  material  is  medically  necessary  for the  evaluation  of  this  patient.  The  submitted 
documentation supports the medical necessity of the requested service. Kothari explains that 
cervical radiculopathy is a clinical diagnosis that may result from a number of causes including 
but not limited to degenerative disease, infection, inflammation, and tumor. Ancillary testing is 
important in localization and in determining pathology in addition to the clinical evaluation. 
Neuroimaging is indicated for most patients with a corresponding neurological deficit present on 
examination  and  is  currently  the  study  of  choice  to  assist  in  confirming  a  compressive 
radiculopathy for diagnostic and treatment purposes. In this case, the patient has symptoms 
suggestive of left cervical radiculopathy with numbness on physical examination in the vicinity of 
the left C3 dermatome. In this clinical setting, an MRI of the cervical spine without contrast 
medically indicated for the evaluation of suspected left C3-C4 radiculopathy. Therefore, MRI 
cervical spine without contrast material is medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
An 18-year-old male enrollee has requested reimbursement for outdoor behavioral health 
services provided from 11/03/20 through 12/31/20. The Health Insurer has denied this request 
and reported that the services at issue were investigational for the treatment of the enrollees 
medical condition. The physician reviewer found that a number of studies have demonstrated 
that outdoor behavioral health (OBH) programs are associated with reduced frequency of 
substance use and improved interpersonal relationships. Gass and colleagues compared the 
effectiveness of three post-acute adolescent substance use situations: outdoor behavioral health 
program (OBH), treatment as usual, and no structured treatment. Results of the study found that 
in the OBH group, completion rates were higher, and the treatment outcomes were 424% better 
as measured by the Youth Outcome Questionnaire. Despite the reported positive benefits of 
OBH, the literature does not support claims that OBH is more effective than other therapies. 
There are very few studies which directly compare outcomes of OBH to other therapeutic 
interventions. Although OBH can be an effective treatment intervention for adolescent substance 
use and mental health disorders, there is no evidence to support the claim that it is superior to 
the standard of care. Although the OBH literature contains a number of studies that suggest that 
participants  show  some  level  of  improvement  on  behavioral  health  outcomes,  there  are 
considerable limitations in the research methodology used to examine these programs and the 
results are not conclusive. Most notably, there is a lack of randomized controlled trials or well-
designed cohort studies that would allow causal conclusions about the impact of OBH to be 
drawn. Review of studies did not reveal OBH to be better than standard treatment. Therefore, 
outdoor behavioral health services provided from 11/03/20 through 12/31/20 was not likely to 
have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
 
An 18-year-old male enrollee has requested reimbursement for outdoor behavioral health 
services provided from 11/03/20 through 12/31/20. The Health Insurer has denied this request 
and reported that the services at issue were investigational for the treatment of the enrollees 
medical  condition.  The  physician  reviewer  found  that  Bowen  and  colleagues  noted  that 
wilderness therapy is adventure therapy that offers a prevention, early intervention, and 
treatment modality for people with behavioral, psychological, and psychosocial issues. It can 
appeal  to  youth-at-risk  who  are  often  less  responsive  to  traditional  psychotherapeutic 
interventions. Overall, this study concluded, For participants in clinical ranges pre-program, 
there was a large, statistically significant reduction in depressive symptomology, and large to very 
large, statistically significant improvements in behavioral and emotional functioning. These 
changes were retained at the three-month follow-up. These findings indicate that wilderness 
adventure  therapy  is  as  effective  as  traditional  psychotherapy  techniques  for  clinically 
symptomatic people. In general, wilderness therapy has been considered residential level of 
care, with components of therapy frequency and intensity that qualify it as such; however, there  is a wide range of wilderness therapy programs with varying degrees of evidence-based practice 
within  each  one.  Overall,  this  patients  multiple  conditions  appear  to  have  required 
comprehensive trauma informed cognitive behavioral therapy and dialectical behavioral therapy 
modalities and significant psychiatric management. There is limited evidence available showing 
that  outdoor  behavioral  health  services  are  superior  to  these  evidence-based  treatments. 
Therefore, outdoor behavioral health services provided from 11/03/20 through 12/31/20 was 
not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
 
An 18-year-old male enrollee has requested reimbursement for outdoor behavioral health 
services provided from 11/03/20 through 12/31/20. The Health Insurer has denied this request 
and reported that the services at issue were investigational for the treatment of the enrollees 
medical condition. The physician reviewer found that in a document outlining principles of care 
for residential treatment, the American Academy of Child and Adolescent Psychiatry stated, The 
best place for children and adolescents is at home with their families. A child or adolescent with 
mental illness should be treated in the safest and least restrictive environment and needed 
services should be wrapped-around to provide more intensive home or community-based 
services. However, due to the severity of an individuals psychiatric illness, there are times when 
a patients needs cannot be met in a community-based setting. The Child and Adolescent Service 
Intensity Instrument (CASII; AACAP, 2007) defines level of service intensity by a combination of 
variables: clinical services, support services, care environment, crisis stabilization and prevention 
services. The Child and Adolescent Level of Care Service Intensity/Utilization System (CALOCUS-
CASII) provides a framework for determining the appropriate level of care for children and 
adolescents in mental health treatment. CALOCUS-CASII also sets parameters for the clinical 
services typically offered at each level of care.  According to CALOCUS-CASII, Level Five: Medically 
Monitored Intensive Integrated Services is the level assigned to most residential treatment 
centers. Per CALOCUS-CASII, This level of service intensity refers to treatment in which the 
essential element is the maintenance of a milieu in which the therapeutic needs of the child and 
adolescent  and  family  can  be  addressed  intensively.  CALOCUS-CASII  guidelines  state  that 
medical  and  psychiatric  services  should  be  available.  Additionally,  non-psychiatric  clinical 
services generally average 8-20 hours per client weekly.  Per the clinical records provided, the 
patient did not receive clinical services at this level of intensity while attending the outdoor 
behavioral  health  program  during  the  period  under  review.  Furthermore,  the  clinical 
documentation does not meet typical standards for residential care. There is no convincing 
explanation offered as to why the patient could not have enrolled in a standard residential 
treatment program instead of the outdoor behavioral health program. Additionally, there is no 
indication that the patient received unique benefits from the outdoor behavioral health program 
that he could not have received at a standard residential treatment facility. The discharge plan 
for the outdoor behavioral health program included a recommendation for the patient to 
transfer to a residential treatment program. Therefore, outdoor behavioral health services  provided from 11/03/20 through 12/31/20 was not likely to have been more beneficial than any 
available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 45-year-old female with a history of atopic dermatitis. The patient states that she 
stopped treatment with Dupixent after experiencing a disruption in treatment from September to 
November 2022. The patient has requested continued treatment with Dupixent. The Health Insurer 
has denied the requested treatment as not medically necessary for the treatment of the patients 
medical condition. This denial is the subject of this appeal and determination. The physician 
reviewer found that the U.S. Food and Drug Administration (FDA) has approved Dupixent for the 
treatment of patients with moderate-to-severe atopic dermatitis whose disease is not adequately 
controlled with topical therapies. A recent consensus article on atopic dermatitis by Boguniewicz 
and colleagues defined moderate-to-severe atopic dermatitis as more than 10% BSA involvement 
and/or involvement of highly visible areas or those important for function and significantly 
impaired quality of life. On review of the current medical literature, Dupixent has the highest-
quality clinical trial evidence for safety and efficacy in atopic dermatitis (Siegels, et al.). The 
records provided for review document that the patient has severe atopic dermatitis and atopic 
neurodermatitis, with 20% BSA involvement. The provider noted that the patient has tried and 
failed treatment with topical steroids, antibiotics, and tacrolimus. The patient has previously 
undergone treatment with Dupixent with significant relief of symptoms. Given these findings, the 
requested Dupixent 300 mg/2 mL, four pens per 28 days is medically necessary for the treatment 
of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 28-year-old female insured has requested authorization and coverage for intravenous (IV) 
Gammagard. The Health Insurer has denied this request indicating that the requested treatment is 
considered investigational for the treatment of the insured's refractory relapsing polychondritis. 
The physician reviewer found  that relapsing polychondritis is a systemic immune-mediated 
disorder that causes inflammation and damage to cartilage-containing structures within the human 
body  (Lekpa  and  Chevalier).  Steroid-dependent,  refractory  and/or  life-threatening  relapsing 
polychondritis is an indication for immunosuppressive or immunomodulatory drug therapy in 
patients with this disorder. The current medical literature suggests that treatment options for 
patients with relapsing polychondritis include therapies such as colchicine, dapsone, methotrexate, 
cyclophosphamide, cyclosporine, azathioprine, mycophenolate mofetil, IVIG, and leflunomide 
(Petitdemange, et al.). Biologic therapies include treatments such as adalimumab, infliximab, 
tocilizumab, rituximab, and abatacept. There is a lack of data supporting the superiority of one 
particular therapy in the treatment of patients with relapsing polychondritis. In this case, the 
records provided for review reflect that the patient has already attempted and failed treatment with 
several standard therapies for relapsing polychondritis including high-dose steroids, dapsone, 
methotrexate, azathioprine, adalimumab, infliximab, abatacept, and cyclosporin. However, the 
records indicate that the patient has responded positively to IVIG. The current medical literature 
also supports a remission of refractory relapsing polychondritis with the use of IVIG. For these 
reasons, the requested IV Gammagard is likely to be more beneficial for the treatment of the 
patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
A 28-year-old female insured has requested authorization and coverage for intravenous (IV) 
Gammagard. The Health Insurer has denied this request indicating that the requested treatment is 
considered investigational for the treatment of the insured's refractory relapsing polychondritis.  
The physician reviewer found that the treatment of relapsing polychondritis is challenging and 
often  lifelong.  Corticosteroids  remain  the  mainstay  of  therapy  options,  but  other 
immunosuppressive agents and biologic agents may be used in combination or as alternatives if 
corticosteroids are inefficacious (Mathian, et al.). The choice of alternative therapy depends on the 
severity and location of the inflammation, as well as the patient's overall health and response to 
previous treatments. The current medical literature has suggested IVIG as an alternative treatment 
option for patients with relapsing polychondritis (Lekpa and Chevalier). IVIG is a preparation of 
antibodies derived from human plasma which has been shown to have immunomodulatory and 
anti-inflammatory effects. IVIG is typically administered every two to four weeks and is generally 
well-tolerated, though the dose and frequency may be adjusted based on the patient's response. In 
this case, the records available for review indicate that the patient has tried and failed treatment 
with  several  standard  therapies,  including  multiple  courses  of  high-dose  corticosteroids, 
methotrexate,  dapsone,  adalimumab,  infliximab,  cyclosporine,  abatacept,  rituximab,  and 
azathioprine. The patient has experienced documented success with IVIG as a treatment modality. 
Therefore, the requested IV Gammagard is likely to be more beneficial for the treatment of the 
patients condition than any available standard therapy.