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

The patient is a 45-year-old female who has been treated by her chiropractor for bilateral neck, right shoulder, elbow, and hand pain. She has found relief with chiropractic treatment but requests two treatments a week until she further improves from her chronic problem. The records reveal ten chiropractic treatments have already been provided. Her chiropractor has given her a broad diagnosis of cervicalgia and muscle spasm. The treating record does not show a treatment plan with goals or development of a home program.This patient has a history of chronic dislocation of her right shoulder that improved with shoulder surgery. A recent cervical x-ray revealed facet arthropathy, hypertrophic changes at C5-6, and hypoplastic development of her C1 area. The Health Plan has denied authorization and coverage for continuing chiropractic care based on lack of medical necessity.Research reveals that specific exercises concurrent with chiropractic care yields a superior result. Two months of chiropractic care have been provided for this patient. Upon review of the record, an x-ray report dated 7/29/04 reveals a hypoplastic development of the posterior arch of the atlas vertebra (C1). Congenital abnormalities of this area of the spine are uncommon yet very significant relative to chiropractic care. Manipulation is an absolute contraindication for patients such as this patient who are at risk of atlantoaxial medical subluxation or dislocation. Provocative physical examination procedures of her cervical spine must be performed with full knowledge of her anomaly and potential instability. The integrity of her transverse ligament may be compromised in the maldevelopment process. Based upon the radiographic findings, continuing chiropractic care is contraindicated in this patient. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 24-year-old male with an approximate one-year history of diabetes who is requesting authorization for an insulin pump. He is presently on a multiple daily insulin injection (MDII) regimen of glargine and supplemental short-acting insulin. On 9/30/04, the patients A1c was 5.9%. Multiple self-monitored blood glucose values submitted from 3/14/04 to 6/11/04 showed excellent control. A 9/30/04 progress note for the patients provider noted great control. As of 10/1/04, the patients endocrinologist has not suggested any changes to the patients current regimen.Analysis and Findings:The patients blood sugars are well controlled with his present MDII regimen. For many people the MDII regimen provides control equivalent to insulin pump therapy. Although pump therapy may provide greater life-style flexibility for the patient, no documentation has been submitted demonstrating a medical need for insulin pump therapy. Therefore, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 54-year-old male who has been managed by a dermatologist for psoriasis. He has had a documented excellent response to Raptiva under conditions of a clinical trial. He would like to continue to receive Raptiva. Light therapies are contraindicated because of his history of skin cancer. Other medications are contraindicated because of increased lipids. The patient is reluctant to use cyclosporine or methotrexate because of their toxicities. The Health Plan indicates the patient must fail a trial methotrexate or cyclosporine before Raptiva can be authorized.Because of the respective liver and kidney toxicities, neither methotrexate nor cyclosporine are reasonable long-term therapies for this patients chronic condition. Furthermore, Raptiva has already demonstrated efficacy in treating this patients condition. For the above reasons, it is reasonable for the patient to forego a trial of methotrexate or cyclosporine and continue with Raptiva therapy. Raptiva is medically appropriate and necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 14-year-old female who has proteinuria, which was diagnosed in August 2004. The provider noted the laboratory was unable to do a split urine specimen so a renal ultrasound and nephrology evaluation were recommended. The Health Plan has denied authorization for a renal ultrasound on the basis it is not medically necessary for evaluation of the patients medical condition.  The clinical information provided does not indicate how proteinuria was demonstrated or whether a urinalysis was repeated. There is no 24-hour urine collection noted or a random urine protein to urine creatinine ratio to quantify the proteinuria. In addition, there is no serum measurement of creatinine or other workup documented. Nevertheless, as proteinuria can be an early marker for kidney disease it is important that the patient undergo further evaluation to see if there is underlying glomerulopathy. The patient might require a kidney biopsy for accurate diagnosis, but without knowing how much protein was in the urine, and whether it was a repeated finding or whether there was also microhematuria, it is difficult to determine which diagnostic tests should be performed. Based upon the information set forth above, I have determined that the requested renal ultrasound is not medically necessary for evaluation of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, a nephrologist should evaluate the patient. If the nephrologist is concerned about reflux nephrology (which can present in young females with proteinuria), abdominal renal anatomy or polycystic kidney disease, a renal ultrasound will be useful and should be authorized
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 46-year-old male who is a C4-5 quadriplegic. Since his injury he has had several electric wheelchairs. Approximately five years ago he required surgery for a decubitus ulcer and was provided a power wheelchair with power tilt to allow for pressure relief. The patient is seeking authorization for a standing power wheelchair. The Health Plan has denied this request.Since the patients surgery noted above there is no record of the patient having further skin difficulties. In September 2003, the patients durable medical equipment provider noted the patients current power wheelchair did not need to be replaced. In addition, the records submitted do not provide any evidence of the patients current equipment requiring replacement because of mechanical issues. Furthermore, the patients current wheelchair is appropriately equipped to meet the patients pressure relief needs. Based upon this information, there is no evidence demonstrating the requested equipment is medically necessary. Therefore, I have determined the Health Plans denial should be upheld
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 58-year-old female with breast cancer and possibly ovarian cancer. She is known to have BRCA-2 mutation and has requested consultation with a gynecologic oncologist. The Health Plan believes the patient can be appropriately evaluated by a general gynecologist and that a referral to a gynecologic oncologist is not medically necessary.General gynecologists have little, if any, cancer-genetic training. The patient should consult with a gynecologic oncologist to understand all of the available treatment options. Any ovarian cancer staging with retroperitoneal resection should be performed by a gynecologic oncologist  not a general gynecologist. Because this patient has a known BRCA-2 mutation and is a known risk for tubal cancer she requires evaluation by a gynecologic oncologist, which is the specialty trained to address the patients cancer-genetic issues and would be the specialty to perform necessary procedures. For these reasons, I have determined the requested referral is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 50-year-old male who suffered a clavicle fracture in July 2004 as a result of a motorcycle accident. He is requesting authorization for a bone growth stimulator to expedite the healing process. The Health Plan has denied this request.The vast majority of clavicle fractures (99%) heal within six weeks by non-surgical means. A bone growth stimulator is not indicated unless a delayed union or non-union develops. These generally are found two to three months following the injury. This patient had no evidence of delayed union or non-union when the stimulator was requested and it appears the equipment was requested to attempt to expedite the healing process. There is no evidence the patient required or requires a bone growth stimulator for medical reasons. Therefore, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a four-year-old male with a history of a cleft lip and palate, which was treated by a cranial facial center. He has undergone reconstructive cleft lip/palate surgery. The records provided indicate the patient has an unrepaired cleft alveolar ridge, communication impairment, and otitis media with effusion. The patient has been seen at the cranial facial center five times and the cranial facial team performed all of the reconstruction surgery needed to date. The Health Plan indicates it is not medically necessary for the patient to continue to receive services from the same cranial facial team.Review of the submitted clinical records indicates the patient has a cleft lip/palate congenital deformity. Part of the deformity is Eustachian tube dysfunction with resultant middle ear effusions and resultant otitis media. The patient is in need of follow-up on a regular basis with an otolaryngologist. In addition, the patient has malocclusion deformities secondary to his cleft lip/palate congenital deformity. His occlusion will change as he grows and as his dentition changes toward permanent dentition. Malocclusion and maleruption of dentition are common with the patients congenital deformity and he will require distraction techniques as well as probable bone grafting after distraction has been completed. This will occur over multiple years. Therefore, the patient needs a dental specialist who can provide distraction techniques and will ultimately need bone grafting by a plastic surgeon or maxillofacial surgeon. Furthermore, the patient needs a speech therapist to evaluate and help with diction problems associated with muscular incompetence. This will change as the child develops and his bony distraction changes his degree of oral and nasal competence in terms of speech. The timing of these processes varies with the degree of nasopharyngeal incompetence and the amount of bony distraction needed. As long as the Health Plan has these specialists available, it is not medically necessary for the patient to return to the same facial cranial center where he has received treatment in the past. While the patient does need evaluation of the above health issues during the course of his growth to adulthood there is no evidence that these services are only available at the patients facial cranial center. As such, the requested referral is not medically warranted for the patients ongoing treatment. Based upon the information set forth above, I have determined that the requested referral is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a four-year-old male with autism has requested a single measles vaccine rather than the combined measles-mumps-rubella (MMR) vaccine. She is concerned that the combination MMR vaccine poses a greater risk to children with neurological deficiencies. The Health Plan has denied authorization and coverage for the single measles vaccine on the basis that the requested vaccine is not medically necessary.The Health Plans denial should be upheld. There is no scientific evidence that links the MMR vaccine or any vaccine to either the cause or exacerbation of autism. Thus, there is no medical justification for splitting the MMR vaccine in this case. The patient should receive the combination MMR vaccine. Therefore, I have determined the requested vaccine is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a four-year-old male with autism has requested authorization for individual doses of the measles, mumps, and rubella vaccines rather than the combination MMR vaccine. She is concerned that the combination MMR vaccine poses a greater risk to children with neurological deficiencies. The Health Plan has denied authorization and coverage for the individual vaccines on the basis that they are not medically necessary.The Health Plans denial should be upheld. There is no scientific evidence that links the MMR vaccine or any vaccine to either the cause or exacerbation of autism. Thus, there is no medical justification for splitting the MMR vaccine in this case. The patient should receive the combination MMR vaccine. Therefore, I have determined the requested vaccine is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 17-year-old female who has hidradenitis suppurativa. She has been treated with oral antibiotics. She has had unspecified topical treatments. Her physician has requested coverage for laser hair destruction for the patients hidradenitis and possible folliculitis. The Health Plan has denied the request on the basis that laser hair destruction is not medically necessary for treatment of the patients medical condition.Laser therapy other than CO2, has not been described specifically for hidradenitis.  In this case, there is no medical justification for laser hair destruction. Based upon the information provided, it does not appear the patient has undergone a full workup. In addition, it appears that conservative treatments have not been exhausted. Furthermore, the efficacy of the requested procedure has not been established in peer-reviewed medical literature. As such, there is no medical justification for use of laser hair destruction in this case. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 15-year-old female with left branchial arch syndrome (hemifacial microsomia) including microtia, mandibular hyperplasia, and secondary dental malocclusion. She was previously treated with external ear reconstruction and mandibular distraction osteogenesis. The patient is currently under consideration for treatment of residual dental malocclusion, mandibular asymmetry, left facial hyperplasia and cranial nerve palsy affecting lip competence. Her provider has recommended orthodontic treatment. The Health Plan has determined orthodontic treatment is not medically necessary for treatment of the patients medical condition.The patient is progressing through staged treatment of left hemifacial microsomia. A functional dental occlusion would be a primary goal of this treatment and she will need orthodontic therapy to achieve that goal. Orthodontic treatment may be the final modality necessary to establish a functional dental occlusion. However, if orthognathic surgery is needed in the future then orthodontic treatment will be coordinated with that surgical procedure. Orthodontic treatment is medically appropriate for treatment of the patients hemifacial microsomia and should be authorized. As such, I have determined that the requested treatment is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 49-year-old woman with a body mass index (BMI) of 47.8. She has undergone the necessary presurgical evaluations in preparation for weight loss surgery. The patient has requested authorization for the duodenal switch procedure. The Health Plan has denied the patients request indicating that the duodenal switch procedure is not medically necessary for treatment of the patients medical condition.Duodenal switch has gained increasing acceptance as several large studies have been published in the last few years. In 2003, Anthone, et al. demonstrated acceptable perioperative morbidity and mortality with duodenal switch. However, at this time there are no randomized, prospective trials establishing the superiority of duodenal switch vs. Roux-en-Y gastric bypass in patients such as this patient with moderate morbid obesity. The more malabsorptive procedures such as duodenal switch can be appropriate in the super morbidly obese where body habitus or massive hepatomegaly makes conventional Roux-en-Y untenable. This patient can be appropriately and effectively treated with Roux-en-Y gastric bypass. The information submitted provides no compelling reason why duodenal switch would be more advantageous for this patient than Roux-en-Y gastric bypass. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 37-year-old female with a body mass index (BMI) of 42. She has requested authorization for gastric bypass surgery. Based on the submitted information, it does not appear the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. The Health Plan indicates the requested procedure is not medically necessary for treatment of the patients medical condition.With a BMI of 42 the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. However, although medically the patient meets criteria for weight loss surgery, she needs to undergo a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. If the evaluation indicates the patient is an appropriate candidate for weight loss surgery, the surgery should be authorized. If the evaluation indicates the patient is not an appropriate candidate for weight loss surgery, the surgery should not be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This patient is a 10-year-old male with short stature. The patients physician began treatment growth hormone therapy and the patient has responded well. The patients parents are requesting continued treatment with growth hormone therapy. In my review of the records I have found the patient to have idiopathic short stature, which was not attributed to growth hormone deficiency or other definable syndrome. He was given growth hormone therapy at 7.5 years at a time when his height was well below the first percentile and he has shown a gratifying and protracted growth response to lie between 10th and 25th percentiles by 10.5 years. On medical grounds, growth hormone therapy should be continued as long as the patient continues to respond or until growth has ceased. In addition, growth hormone therapy for patients such as this patient is supported by the Food and Drug Administration and the American Association of Clinical Endocrinologists (see citation above). Continued growth hormone therapy is medically reasonable and appropriate for this patient. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This 61-year-old male was diagnosed with prostate cancer in May 2004. His Gleason score was 7 (3+4) involving 5%-10% of the entire specimen from the right side and his stage was T1c. His radiation oncologist has offered him brachytherapy, and external beam irradiation. His medical oncologist has offered him hormonal therapy. His urologist has offered him prostatectomy. The patient would like to have proton beam therapy.Based on Partins Tables the patient has a 43% chance his tumor is confined to the prostate, a 47% chance of capsular involvement, an 8% chance of seminal vesicle involvement, and a 2% chance of pelvic lymph node involvement.Proton beam is a very sharply confined beam of radiation and is not well suited for this patients prostate cancer. Although proton beam can deliver a 10-15% higher dose when compared to photon beam, conventional radiation, the brachytherapy offered to this patient can deliver 100% to 150% higher dose than the conventional radiation without increase in side effects or complications. Considering his Gleason score of 7 (3+4), neoadjuvant hormone therapy (NHT) is also recommended. Based upon this information, the patient will be better served through other available treatments. Therefore, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.