Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for outdoor behavioral health therapy services (wilderness program).Findings: Two out of three physician reviewers found that the outdoor behavioral health therapy (wilderness program) services at issue were not likely to have been more beneficial than any other available standard therapy for the patients condition.Despite the reported positive benefits of outdoor behavioral health programs, the literature does not support claims that outdoor behavioral health programs are more effective than other therapies. Very few studies directly compare outcomes of outdoor behavioral health programs to other therapeutic interventions. A scoping review conducted by Dobud and Harper found only 13 such studies and concluded that few significant differences were found to pinpoint specific ingredients required to produce significant change. Little to no differences were found to isolate specific therapeutic factors. Although outdoor behavioral health programs 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 more beneficial than any other available standard therapy. Although the outdoor behavioral health program 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 outdoor behavioral health programs to be drawn. Accordingly, the outdoor behavioral health therapy (wilderness program) services at issue were not likely to have been more beneficial than any other available standard therapy for the patients condition.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial than any other available standard therapy for the patients condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in psychiatry, with subspecialty certification in child and adolescent psychiatry, and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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 brand Xopenex inhaler and brand Xopenex nebulized solution.Short-acting beta agonists (SABA), including brand-name Xopenex inhaler and brand-name Xopenex nebulized solution, are approved by the U.S. Food and Drug Administration, supported by the medical literature, and included in professional treatment guidelines for the management of asthma. In this case, the patient has tried and failed other SABA alternatives due to severe agitation/anxiety. Given concurrent anxiety and attention deficit hyperactivity disorder, the patient has benefited from the lung-specific stereospecificity of levalbuterol (Xopenex), which has minimized off-target, systemic adrenergic effects. Thus, brand Xopenex inhaler and brand Xopenex nebulized solution are medically necessary for the 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 internal medicine with sub-specialty certification in pulmonary disease 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 enrollees parent has requested authorization and coverage for Inlyta (axitinib). While there is a lack of evidence from strict randomized clinical trial evidence due to the rarity of soft tissue sarcomas, phase 2 clinical trials have shown promise regarding the use of axitinib and pembrolizumab. Wilky and colleagues report in single-center, single-arm, phase 2 trial of 33 patients with histologically confirmed advanced or metastatic sarcomas, including alveolar soft-part sarcoma, axitinib plus pembrolizumab had manageable toxicity and that preliminary activity in patients with advanced sarcomas warranted further investigation in randomized controlled trials. The National Comprehensive Cancer Network (NCCN) guidelines specifically mention the use of pembrolizumab in the treatment of certain soft tissue sarcoma such as undifferentiated pleomorphic sarcoma. In this case, the patient has a diagnosis of advanced undifferentiated pleomorphic sarcoma. The patient has exhausted standard therapies and the provider has recommended treatment with a combination of pembrolizumab and axitinib. Therefore, Inlyta (axitinib) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Inlyta (axitinib) is 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 medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in internal medicine with sub-specialty certifications in medical oncology and hematology and are actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certification in medical oncology 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: An enrollee has requested authorization and coverage for Tepezza (teprotumumab) 500 mg.According to Hiromatsu and colleagues, Graves ophthalmopathy is an autoimmune disorder of the orbit that is clinically relevant in 25-50% of patients with Graves disease. Complications of Graves ophthalmopathy include inflammation, proptosis, and/or diplopia. Glucocorticoid therapy, which has been the mainstay of treatment for Graves ophthalmopathy, has had limited efficacy and presents safety concerns. Teprotumumab is a novel therapy for treatment of patients with active, moderate-to-severe Graves ophthalmopathy. Smith and colleagues state that teprotumumab has a favorable safety profile and has demonstrated remarkable effectiveness in moderate to severe, active Graves ophthalmopathy. In this case, the patient has been diagnosed with Graves ophthalmopathy (thyroid eye disease). Notes indicate that the Graves ophthalmopathy is active and manifests as irritation, lacrimation and diplopia. The medical evidence supports the requested medication in this clinical setting. Therefore, Tepezza (Teprotumumab) 500 mg is medically necessary for the 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 internal medicine with subspecialty 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 patient has requested reimbursement for radiation therapy services. Findings:  The physician reviewer found that atient is noted to have moderately differentiated estrogen receptor (ER) positive, progesterone receptor (PR) positive, invasive ductal carcinoma with micropapillary features. She underwent treatment with surgery and intraoperative radiation therapy (IORT). The records provided for review support that this patient meets the National Comprehensive Cancer Network (NCCN) guidelines for the use of IORT for the treatment of patients with breast cancer (Daly, et al.). In addition, the patient also meets the American Society of Clinical Oncology (ASCO) criteria for the use of IORT in patients with invasive ductal cancer. Phase 3 studies have shown equivalent outcomes in patients who undergo standard radiation therapy and IORT. The benefits of IORT include reduced visits to the treatment facility, the ability to treat a smaller volume, and fewer toxicities due to a smaller treatment field than with conventional radiation therapy. Given this support, the radiation therapy services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 radiation oncology 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 patients parent has requested reimbursement for orthodontic services, CPT D8670. Generally, a handicapping labio-lingual deviation (HLD) score over 25 describes a handicapping malocclusion requiring orthodontic treatment. In this case, while the documented HLD score was 27, the submitted records appeared to show that this score was high. In this clinical setting, generous calculation of the HLD score would be 22, below the threshold for a handicapping malocclusion. Therefore, orthodontic services, CPT D8670, were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is licensed D.D.S., board certified in dentistry 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 nivolumab (Opdivo). Currently, there is a lack of data to support the long-term safety and efficacy of Opdivo in the treatment of Ewing sarcoma. One study reported a response of cabozantinib with Opdivo in renal cancer, which is a different histology than Ewings sarcoma. Guven and colleagues discussed findings suggesting a response of Ewings sarcoma to a combination of Opdivo with Taxotere. The records provided for review document that this patient has already been treated with Taxotere with progression of disease. Furthermore, the NCCN guidelines do not endorse treatment of Ewing sarcoma with Opdivo, and this indication has not been approved by the FDA. Therefore, the requested nivolumab (Opdivo) 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 requested nivolumab (Opdivo) 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 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 reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brachioplasty, breast lift and excess skin removal surgeries. The American Society of Plastic Surgeons practice parameters on the surgical treatment of skin redundancy for obese and massive weight loss patients notes that when surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature. In this case, the documentation show that the patient has some residual fatty tissue fullness in her epigastric region, minimal abdominal skin laxity, and no abdominal pannus. While the patient reports rashes, the documents do not reflect that they are resistant to appropriate medical treatment. There is no functional disability from the patients reduced breast size and moderate breast ptosis. Therefore, brachioplasty, breast lift and excess skin removal surgeries are not medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, skin laxity after massive weight loss is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. It is not an abnormal structure of the body. It is a normal structural change that is an accommodative response to the gain or loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. While the patient reports rashes, the documents do not reflect that the rashes are resistant to appropriate medical treatment. The requested services are not a surgical correction for normal function. For these reasons, brachioplasty, breast lift, breast augmentation, and excess skin removal surgeries are not reconstructive in nature for this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve block therapy. Current medical literature supports the use of greater occipital nerve blocks for the treatment of chronic migraine headaches. In a systematic review and meta-analysis, researchers report that peripheral nerve blocks have long been used to reduce the frequency and severity of migraines, and that greater occipital nerve blocking should be recommended for use in patients with migraines. Researchers note that greater occipital nerve block intervention can significantly alleviate pain and reduce the number of headache days and medication consumption. In this case, the patient has chronic migraines and had failed multiple medications. Given that the patient reported relief with peripheral nerve blocks in the past, the service at issue was likely to have been more effective than other therapies in reducing this patients migraine pain scores, and the frequency and duration of his migraines. Therefore, occipital nerve block therapy was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the occipital nerve block therapy at issue was 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 service at issue was 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 overturned. Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in neurology and are actively practicing. Physician reviewer 2 is board certified in neurology with sub-specialty certification in vascular neurology 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: An enrollee has requested authorization and coverage for testosterone pellet, 75 mg.According to Shoskes and colleagues, the goal of testosterone replacement therapy is to return serum testosterone levels to within physiologic range and improve symptoms in hypogonadal men. Some of the symptoms aimed to improve upon include decreased libido, erectile dysfunction, infertility, hot flashes, depressed mood, and loss of muscle mass or hair. There is evidence that testosterone pellets are effective in the treatment of hypogonadism. Given the patients ongoing treatment with testosterone, replacement by an effective means is the only pertinent issue, and any replacement can be titrated and used safely to achieve normal levels with efficacy. Thus, testosterone pellet, 75 mg is medically necessary for the 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 urology 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 reimbursement and prospective authorization and coverage for the brand name medication, NuvaRing. The U.S. Food and Drug Administration (FDA) describes the NuvaRing as an estrogen/progestin combination hormonal contraceptive that is used continuously for three weeks, followed by a one- week ring-free interval. It is highly effective when used consistently and correctly. In this case, the patient reports poor tolerance with the generic medication and requests the brand name NuvaRing. Given that the records do not document contraindications to estrogen or progestins and the wide range of individualized tolerance to hormonal contraceptive options, the requested medication is medically indicated. Therefore, the brand name medication, NuvaRing, was and is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was and 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 obstetrics and gynecology 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.