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

This patient is a 37-year-old female who was diagnosed with medullary thyroid cancer (MTC) in August 2005. Her initial surgical procedures were total thyroidectomy, left neck dissection, limited right neck dissection, and parathyroid autotransplantation. The patient was noted to have a pulmonary metastasis that was also surgically removed. She then received radiation therapy. In June 2006 a PET scan demonstrated additional disease in the cervical and the iliac regions. The patient sought consultation where she was evaluated by a Head and Neck Oncology surgeon and a Medical Oncologist. Repeat imaging performed including MRI, CT and neck ultrasound which revealed multiple (5) cervical tumors. The patient has requested transfer of her care to MD Anderson Cancer Center for ongoing evaluation and treatment of her metastatic medullary thyroid cancer.  The Health Plan denied her request citing a lack of medical necessity.Following her diagnosis in August 2005, the patient has been treated surgically and with radiation therapy. She has documented recurrent disease in the cervical and iliac regions. The recommendation from the Head and Neck Oncology surgeon at MD Anderson was for continued observation taking into consideration the surgical risks and the potential indolence of this tumor. The Medical Oncologist essentially deferred to the Head and Neck Oncology surgeon regarding surgical necessity and recommended continued observation as a reasonable option if surgery was not needed. This recommendation was apparently based upon current the chemotherapys lack of efficacy, the potential for slow progression, and the hope for future availability of a clinical trial examining the efficacy of biologic therapy in sporadic MTC. Clinical trials are not open currently, but may at some point be available at sites across the United States.The current recommendation from MD Anderson is for continued observation and assessment of tumor growth.  There is no evidence to suggest that either imaging or treatment as currently recommended at MD Anderson would lead to a better outcome than the provision of those services by the Health Plan. Although an uncommon tumor, the options outlined by the consulting specialists at MD Anderson are available to the patient within her Health Plan. Therefore, I have determined the requested services are 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 54-year-old male with dyslipidemia who has been treated simultaneously with Vytorin (simvastatin and ezetimibe) and niacin. His provider has recommended that Omacor be added to his medication regimen and has submitted a request for authorization.  The Health Plan denied the request citing a lack of medical necessity.There is no clinical support for the argument that gemfibrozil is contraindicated due to elevated transaminases. Omega 3 fatty acids are not generally considered first-line therapy for dyslipidemia and standard therapies are likely to be effective for treatment of the patients condition. The documentation provided does not indicate other therapies have been tried and failed. Therefore, I have determined the requested medication 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 21-year-old female who underwent arthroscopic knee surgery in August 2005. Postoperatively she utilized an electronic controlled thermal therapy unit as prescribed by her orthopedic surgeon. The patient is now requesting reimbursement for the cost of the device. The Health Plan denied her request based upon their determination that the thermal therapy unit was not medically necessary following the patients surgery. A thermal (cold) therapy unit is commonly prescribed by surgeons for postoperative rehabilitation following reconstructive surgery. This device is extremely helpful in relieving postoperative pain and swelling. The pad and unit are easy to use, can be applied for long periods of time and give a more uniform application of the cold to the affected area. Therefore, I have determined the device at issue was 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 43-year-old female who underwent an in vitro fertilization (IVF) cycle in August of 2005. Her diagnosis is not clear from the record, but it is assumed that she had a history of infertility given the notation of diminished ovarian reserve. Prior to the initiation of the IVF cycle the patient was tested for immunologic abnormalities. Serum %CD56, %CD19+ cells, and CD5+ levels were elevated, serum antithyroid antibodies were positive and a serum IgM for phosphoethanolamine was borderline positive. The patient underwent the IVF cycle which yielded 13 eggs and 10 fertilizations. There were seven embryos transferred and three discarded. The patient was offered and given IVIG treatment prior to the embryo transfer. Serum BHCG levels in September 2005 were each 8, and negative in the end of September 2005. The patients request for reimbursement for the cost of the IVIG therapy was denied by the Health Plan citing a lack of medical necessary.The 2004 Practice Committee Opinion of the American Society for Reproductive Medicine concluded that IVIG therapy for recurrent miscarriage is an experimental treatment and should only be offered in the context of a research study.  IVIG treatment for reproductive disorders in general and recurrent miscarriage in particular, has been investigated in small studies over the past decade in Europe and the United States. Although a few of the studies showed modest benefit in properly characterized patients with recurrent pregnancy loss, there is limited peer-reviewed, published work in this area and the efficacy of IVIG therapy in couples with infertility not been clearly established. A consensus of support for IVIG treatment is lacking and additional randomized, controlled trials are needed to determine if there is a benefit in reproductive outcomes. Currently, there is no convincing evidence in the medical literature that IVIG treatment is efficacious in a patient with infertility, whether or not the patient is undergoing in vitro fertilization. Therefore, I have determined the therapy at issue was 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 25-year-old female with a body mass index (BMI) of 37.3 and significant comorbid conditions.  She indicates that she has researched all the surgical procedures and has selected the duodenal switch operation for treatment of her obesity.  The patient has completed a psychological evaluation and was deemed an appropriate candidate for weight loss surgery. The Health Plan has denied coverage for the duodenal switch surgery asserting that this surgical procedure is not medically necessary for treatment of the patients condition.This patient clearly meets the criteria set forth by the National Institutes of Health for surgical treatment of obesity with a BMI of 37.3 and co-morbid conditions.  The duodenal switch operation has been shown to be effective for patients with a BMI of less than 50. Additionally, there is no data indicating that nutritional deraignment after the duodenal switch operation is any more prevalent or more serious than what is encountered with the gastric bypass operation. In fact, the lifestyle of patients after duodenal switch is generally free of the ill effects of the gastric bypass, such as the dumping syndrome and intolerance of solid foods.  As cited above, there is a large body of scientific evidence available that shows the duodenal switch operation is more durable with a better long-term success rate when compared to the gastric bypass or the Lap Band operation.  Based upon the information set forth above, I have determined the requested duodenal switch bariatric surgical procedure 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 36-year-old female who underwent Lap-band surgery in June 2004, and reports that after months of attempts to control her subsequent nausea and vomiting she elected to have the band removed. She then underwent a gastric bypass operation in July 2005. She reports only a 10-pound weight loss following that procedure. The patient at this time is reported to be 56 weighing 241 pounds with a body mass index (BMI) of 39. Her comorbid conditions include gastroesophageal reflux disease (GERD), asthma, exertional dyspnea, depression and anxiety. The patients provider has proposed gastric bypass revision to reduce the size of the patients stomach pouch and outlet. Review of the clinical evidence indicates the patients two previous weight loss surgical procedures were unsuccessful. The patients first procedure, the Lap-band, has a significant published rate of solid intolerance, nausea and vomiting associated with the procedure. After the gastric band was removed the patient underwent gastric bypass, also without success. The scientific data shows duodenal switch has the best long-term success of all weight loss surgical procedures. There is one peer-reviewed, published article that reports the outcome of patients with multiple weight loss surgical procedures. This article not only demonstrates the superior long-term outcome of the duodenal switch as a revisional operation, but also shows that patients with multiple previous restrictive operations (Lap-band, gastric bypass, etc.) will fail any other revision unless they have an operation that limits absorption as well.  The patient reports GERD as a comorbid condition. If her gastrojejunostomy anastomosis is reduced from 2.5 cm to 1.5 cm as proposed by her surgeon, it is likely the patients reflux disease will significantly worsen. Thus, although the patient meets criteria for a revisional weight loss procedure, the proposed procedure is not likely to result in adequate weight loss and will probably worsen her reflux disease. 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 36-year-old female who has a body mass index (BMI) of 41 with obesity- related comorbidities. The patients provider has recommended Lap-band for treatment of the patients morbid obesity. The patient has been evaluated by a psychologist and was found to be appropriate for weight loss surgery, though she may require follow-up to encourage her to maintain her therapeutic regimen. The Health Plan has denied authorization and coverage for the Lap-Band procedure. At issue is whether the requested procedure is medically necessary for treatment of the patients condition.This patient meets NIH criteria for bariatric surgery. Since FDA approval of the Lap-band in 2001, the medical literature has documented its efficacy. While it is true that initial weight loss is more modest with the Lap-band than with Roux-en-Y gastric bypass or the duodenal switch procedure, morbidity is far less. Furthermore, there is increasing data showing that weight loss continues up to three years with the Lap-band, thus approaching weight loss levels associated with the more invasive procedures. Given the decrease in morbidity and mortality associated with the Lap-band procedure, and its potential for significant weight loss, the procedure is medically appropriate for this patient and should be authorized.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 60-year-old female with cystic fibrosis. She has had a bilateral lung transplant for which she will require lifelong immunosuppression and probable steroid treatment. She was found to have worsening osteopenia, a problem typically seen in cystic fibrosis patients because of malabsorption of calcium or vitamin D, potentially complicated by steroid treatment.The provided records are not entirely clear, but it appears that her DEXA scan results gradually worsened through October 2004 despite taking Fosamax. She was then switched from Fosamax to IV pamidronate every three months, and the DEXA scan performed in December 2005 shows improved results at the left hip and lumbar spine. The patient has requested authorization and coverage for continued IV pamidronate, which the Health Plan has denied.The patient has cystic fibrosis, historically associated with osteoporosis related to malabsorption of calcium and/or vitamin D. She also has had a bilateral lung transplant requiring long-term treatment with immunosuppressives and steroids, further increasing her risk for bone loss. She has already been shown to have worsening osteopenia while taking Fosamax, and has further demonstrated improved DEXA results only after switching to IV pamidronate. The submitted literature includes reports of IV pamidronate being as effective as oral bisphosphonates in patients unable to use oral agents. Supporting letter from the patients cystic fibrosis clinic notes the use of IV pamidronate to be an accepted part of the protocol in cystic fibrosis clinics.In conclusion, the patient has a continuing and significant risk for bone loss, has already failed Fosamax, and has demonstrated a beneficial response to IV pamidronate. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 52-year-old female with type II diabetes mellitus, diagnosed about nine years ago. In July 2005 she was on Glipizide 10mg twice per day and Avandia 4mg twice per day and her HgbA1C was 9.8%. The record indicates the patient does not tolerate Metformin due to diarrhea, and she was started on Lantus insulin at 18 units. The patients weight was reported as 240 pounds. In December of 2005 her HgbA1C decreased to 8.5% and she had a weight loss of five pounds. At that time, she was started on Byetta 5mcg twice per day. In March 2006 the patients HgbA1C had decreased further to 7.1% and she lost an additional three pounds. In June 2006 her HgbA1C was down to 6.7%.  The patient has requested reimbursement and continued authorization and coverage for Byetta. The Health Plan denied her request based upon a determination that the medication was/is not medically necessary.The patient is a type II diabetic who is overweight and was previously managed with insulin injections and oral Glipizide and Avandia. After adding Byetta to her regimen in December 2005 her HgbA1C dropped from 8.5% to 6.7% and she has lost three pounds.  The FDA approval of Byetta is limited to patients with type II diabetes who take sulfonylurea and/or Metformin only because the clinical trials involved those two medications. Current studies of Byetta in combination with thiazolidinediones (TZDs) such as Avandia have been submitted to the FDA and are awaiting approval.  Additional studies of Byetta in combination with insulin are also being conducted.  Byetta has been shown to be effective for patients with type II diabetes who are insulin resistant and have beta cell reserve. This patient is within that class of patients and responded well to treatment with Byetta as demonstrated by her weight loss and improved HgbA1C. Many endocrinologists have recognized the benefit of Byetta for patients like this one and it is widely prescribed. The patient has improved her diabetic control with the addition of Byetta and continued treatment may help to prevent long-term diabetic complications. Therefore, I have determined the medication at issue was/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 63-year-old female with multiple medical problems including bipolar disorder and severe osteoarthritis. She was hospitalized in April 2006 for urosepsis complicated by acute renal failure and lithium toxicity. The patient was encephalopathic and had peripheral neuropathies during her acute stay. Her cognitive functioning improved but she had slow recovery of motor function. The patient was admitted to the skilled nursing facility (SNF) for rehabilitation in May 2006. She made good progress initially, but her progress slowed over the final two to three weeks of occupational therapy (OT) and physical therapy (PT).  Her therapists noted her osteoarthritis as contributing to her limited progress.  PT and OT services were discontinued in June 2006.  The patient and her representative have requested authorization and coverage for continued skilled nursing services.  The Health Plan denied the request citing a lack of medical necessity after June 2006.Review of the submitted clinical evidence demonstrates the patient had met her OT goals related to ADLS by week ending June 2006. She did show some increase in strength, but her functional progress was noted to be limited by her knee pain. The PT progress notes indicate limited progress in bed mobility, transfers and ambulation after week four.  It is also noted that weight bearing and ambulation were limited by her osteoarthritis. It appears that by June 2006 the patient had maximized her functional status and would not benefit further from continued inpatient skilled rehabilitation. Therefore, I have determined that continued skilled nursing facility services after June 2006 were 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 56-year-old female with painful onychomycosis of the fingernails. She is currently taking Remicade and methotrexate for ankylosing spondylitis. Her blood tests, including liver function tests, have been normal. Use of Penlac solution topically has been denied by the Health Plan because the patient has not tried and failed a course of oral Lamisil. The Health Plan further states that Lamisil is not contraindicated in a patient taking Remicade. The treating dermatologists records document the patient is taking both Remicade and methotrexate. The patients letter of June 2006 indicates it is the methotrexate she is taking that is a contraindication to Lamisil.Lamisil tablets are contraindicated for patients taking methotrexate. Both medications are potential causes of hepatotoxicity and use of both medications concurrently would increase the risk of hepatotoxicity. Because oral antifungals are contraindicated in patients taking methotrexate, it is medically necessary for this patient to be treated with topical Penlac solution. Therefore, I have determined the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 49-year-old female patient with a history of breast cancer. She is undergoing chemotherapy. She has a BMI of 35.4 with multiple comorbidities including hypercholesterimia, GERD, degenerative joint disease, and hypertension. The patient has had documented attempts of failed non-surgical approaches to weight loss and is now requesting authorization for laparoscopic restrictive vertical gastroplasty/gastrectomy. The Health Plan has denied her request. The patient meets NIH criteria for weight loss surgery with a BMI greater than 35 and her documented comorbid conditions. It is clear that weight loss will not only benefit the patients general health, but also the long-term outcome of her breast cancer. This is based on the fact that the hormonal changes that follow weight loss are consistent with reduction of estrogen level, which is stored/converted in peripheral adipose cells. As the patients providers indicate, a purely gastric restrictive procedure is more appropriate in this patient given her history of breast cancer. Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. Documentation of psychological clearance should be obtained prior to weight loss surgery.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 48-year-old female with problems related to dysfunctional menstrual bleeding since 2001. In addition, she is treated for severe rheumatoid arthritis and diabetes. In January 2006 the patient presented with the complaint of bleeding from December 2005 to the present; over a 5-day period, the bleeding was described as heavy enough to require changing a pad every 30 to 45 minutes. The providers workup included a normal endometrial biopsy, normal thyroid function, and PTT which was pending but also presumed normal. An ultrasound in January 2006 confirmed the presence of several small (less than 2cm) intramural uterine fibroids in addition to a 1cm submucosal fibroid. The patient was given a trial of progestins in an attempt to control her bleeding as she was not a candidate for oral contraceptives due to her history of diabetes.  The hormone therapy was not successful and caused significant side effects. The patient and her provider discussed the surgical options and the patient refused a hysterectomy, stating that the reduced level of activity postoperatively would exacerbate her arthritis and cause her a great deal of pain. Alternatively, her provider proposed a hysteroscopic resection of the submucus fibroid with concurrent endometrial ablation as this is an outpatient procedure with minimal postoperative down time. The patients provider submitted a request for authorization of the hysteroscopic myomectomy and ablation.  The request was denied by the Health Plan on the basis that it was not medically necessary.The patient is an appropriate candidate for hysteroscopic myomectomy of a small submucus fibroid with concomitant endometrial ablation. ACOG endorses the use of hysteroscopic myomectomy and/or ablation as an alternative to hysterectomy. While acknowledging that as many as one third of the women who undergo ablation go on to require hysterectomy, the ACOG guidelines also cite studies that indicate the failure rate increased over time, and only 8.5% of ablated patients required hysterectomy within a three-year period. The patient will presumably enter menopause within three to five years and does not require permanent amelioration. A submucosal myomectomy will increase the likelihood of successful reduction in bleeding. In one large study, women who underwent both ablation and hysteroscopic submucosal myomectomy had only an 8% chance of undergoing a second surgery within a six-year period. The patients concerns with regard to her rheumatoid arthritis along with her diabetes combine to make her a rather poor surgical candidate; ablation with hysteroscopic myomectomy presents fewer surgical risks than hysterectomy. Finally, ACOG Guidelines for Quality Assurance require that there be no remedial endometrial pathology (e.g. submucus fibroid) before a hysterectomy is considered for abnormal uterine bleeding in premenopausal women.Based upon the information set forth above, I have determined the requested procedures are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.