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

Physician 1: The patient is a 46-year-old male with degenerative disc disease. He has had a positive discogram at L4-5 and L5-S1. His provider believes the L5-S1 disc is responsible for the patients pain and is recommending artificial disc replacement with the Charite disc. The Health Plan considers this procedure experimental. The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement surgery for this patient. The proposed procedure is still under investigation and is not considered standard of care. The long-term success rate and safety profile remain unknown. Because there is no evidence supporting the long-term safety and efficacy of the proposed procedure, I have determined the requested procedure 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. Physician 2: The patient is a 46-year-old male with degenerative disc disease. He is seeking authorization for artificial disc replacement utilizing the Charite disc. The Health Plan has denied this request because it considers artificial disc replacement experimental.The current clinical evidence regarding the Charite III disc has allowed for Food and Drug Administration (FDA) approval that it is not inferior compared to fusion. Similarly, current studies appear to indicate it is not worse than fusion. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. A 300-patient FDA regulated investigational device exemption trial with long-term follow-up is underway. Without the results of this trial the Charite III disc replacement remains experimental. Furthermore, it is not established as superior to fusion. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 3: The patient is a 46-year-old male with degenerative disc disease with involvement at L4-5 and L5-S1. The patient has undergone IDET and obtained no relief. He is requesting authorization for artificial disc replacement at L5-S1. The Health Plan has denied authorization for the requested procedure. The proposed procedure is experimental without established long-term efficacy. The best published results reveal outcomes equivalent to fusion. However, the majority of studies show a failure rate of 35%. Furthermore, the long-term safety profile is unknown. In addition, there are other treatments available. For these reasons I have determined the requested procedure 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 55-year-old female seeking abdominoplasty for a hanging panniculus post gastric bypass, which apparently was performed in 1986. The patients stated weight is 151 pounds and her height is 60 indicating a body mass index of greater than 30. This suggests that the patients weight loss surgery has failed. The Health Plan has denied coverage for an abdominoplasty on the basis that it is not medically necessary. Review of the examination records of the plastic surgeon and the patients photographs demonstrate an obese female with a double pannus. Thus, it does not appear the patient has a true hanging pannus. Furthermore, although there is patient derived history of intertrigo, there is no clinical evidence of the same. Thus, there is insufficient evidence that an abdominoplasty is medically indicated. As such, 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 five-year-old female with a history significant for cleft palate and chromosomal abnormalities complicated by recurrent otitis media requiring bilateral myringotomies x 3. The patient has been receiving speech therapy for expressive and receptive language delays, oral motor production disorders, and verbal apraxia. There is also mention of an auditory processing disorder, but no discussion of symptoms associated with this disorder. A request has been made for coverage of speech therapy twice a week. The Health Plan has denied this request. Although further standardized testing would be helpful for this patient, the goals outlined are functional in nature. In addition, records demonstrate the patient has made significant gains towards her goals. For example, her expressive language has increased to 100 words and there has been a marked increase in her phonic inventory. Because the patient is making objective significant gains, further therapy is medically indicated. The patient should continue to receive speech therapy for another six months, at which time she should be re-evaluated to determine whether she is meeting objective, functional goals.Based upon the information set forth above, I have determined the therapy at issue is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 40-year-old male with degenerative disc disease. He has had a positive discogram at L5-S1. His provider is recommending artificial disc replacement with the Charite disc. The Health Plan considers this procedure experimental. The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement surgery for this patient. The proposed procedure is still under investigation and is not considered standard of care. The long-term success rate and safety profile remain unknown. Because there is no evidence supporting the long-term safety and efficacy of the proposed procedure, I have determined the requested procedure 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. Physician 2: The patient is a 40-year-old male with degenerative disc disease. He is seeking authorization for artificial disc replacement utilizing the Charite disc. The Health Plan has denied this request because it considers artificial disc replacement experimental. The current clinical evidence regarding the Charite III disc has allowed for Food and Drug Administration (FDA) approval that it is not inferior compared to fusion. Similarly, current studies appear to indicate it is not worse than fusion. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. A 300-patient FDA regulated investigational device exemption trial with long-term follow-up is underway. Without the results of this trial the Charite III disc replacement remains experimental. Furthermore, it is not established as superior to fusion. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 3: The patient is a 40-year-old male with degenerative disc disease at L5-S1. The patient has undergone a number of treatments including traction, chiropractic, epidural injections, and massage therapy without success. He is requesting authorization for artificial disc replacement. The Health Plan has denied authorization for the requested procedure. The proposed procedure is experimental without established long-term efficacy. The best published results reveal outcomes equivalent to fusion. However, the majority of studies show a failure rate of 35%. Furthermore, the long-term safety profile is unknown. In addition, there are other treatments available. For these reasons I have determined the requested procedure 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 16-year-old female with a history of depression, cutting on herself, running away from home, arguing with her parents, drug use, and overdosing on cold medication. She was admitted to residential treatment on 10/18/04 where she remained until 12/3/04. Her diagnoses included major depression, recurrent; polysubstance abuse; and oppositional defiant disorder. She was treated with a variety of psychotherapies as well as Prozac 20mg and Trileptal 300mg and was felt to have benefited a good amount. Her psychiatrist noted on 11/26/04, no aggressive or impulsive behaviors-denies urge to use drugs-denies suicidal ideation, and noted her mood as good with congruent affect. By 11/30/04, one of her therapists noted the patient as teary but able to contain emotions. On 12/1/04, she was noted as in good mood this morning. Client is very excited about going home tomorrow. However, on 12/2/04, she was noted as very frightened to go home and not doing well. Client mentioned she feels safe at CFD, client committed to write about what her fears are of going home. With regard to her home pass, a progress note of 12/1/04 indicates her pass went well and she was able to resolve conflict with her mother by taking a self time out and journaling all her feelings. She reported that she thought about using but was able to not use on pass. Her psychiatrists note of 12/2/04 indicates, Speech and activity are unchanged. Mood is good with congruent affect. A request has been made for reimbursement for residential treatment services the patient received from 11/30/04 to 12/3/04. The Health Plan indicates the services at issue were not medically necessary for treatment of the patients condition. By all accounts, this patient was quite ill with the aforementioned diagnoses as well as an underlying borderline personality organization, and her condition warranted residential treatment. In this context, a patient should be afforded the proper opportunity to segue to outpatient treatment. The patients chart notes, for example, point to her not being entirely settled about returning home. A home pass to assess just how well she might fare was also necessary, and was obtained by 12/1/04. However, it does not seem medically reasonable to cite the patient as necessarily ready for discharge four days prior to the slated discharge simply because she was not flagrantly acting out by that earlier point. The services at issue were medically appropriate and indicated to allow the patient to transition from residential care. As such, I have determined that the services at issue were 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 41-year-old male requesting authorization and coverage for surgical removal of a large lipoma of the abdomen. Records submitted for review include a photograph and medical records from the patients primary care physician and plastic surgeon including a CT scan report indicating probable lipoma of the abdominal wall. The Health Plan has denied coverage for the requested procedure on the basis it is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld. There is no medical indication for removal of the lipoma. The submitted documentation includes no evidence the lipoma is painful or so large that it interferes with everyday function. Thus, surgical removal of the lipoma is not medically warranted. Accordingly, 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 37-year-old male who has experienced headaches (muscle tension and cluster headaches) since the age of 19. Results of a neurological exam and MRI scan were negative. The submitted medical records reveal the patient has been tried on a large number of medications and treatment modalities without success. The patients neurologist provided Botox injections to the patient, which were effective for a five-month period. The patients neurologist has suggested further use of Botox injections. The Health Plan indicates Botox is not medically necessary for this patient. Upon review of the submitted clinical evidence, the diagnosis of cluster headaches appears appropriate. Cluster headaches are a form of migraine, typically seasonal, that are very debilitating and exceptionally difficult to treat. Cluster headaches can be devastating and should be treated by effective means. Botox injections have proven effective for this patient and should be continued as long as the patient experiences benefit. Therefore, I have determined that 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: Upheld Decision of Health Plan

The patient is 56-year-old man who has a T1c No Mo cancer of the prostate. His Gleason score is 6(3+3). The patients PSA increased from 4.3 in August 2004 to 6.2 in November 2004. Results of core biopsies showed 1 of 7 containing less than 5% volume of cancer and 6 of 7 cores were benign. The patient has been offered conventional radiation therapy, intensity-modulated radiation therapy (IMRT) and brachytherapy (seeds). He prefers to undergo conformal proton beam therapy. The Health Plan has denied coverage for the requested therapy on the basis it is not medically necessary for treatment of the patients medical condition.Analysis and Findings:The patient has a low stage, low grade and minimal volume cancer of the prostate. This volume of tumor is small enough to be highly curable by conventional radiation therapy. IMRT is likely to cure the patient and will result in fewer side effects than conventional radiation therapy. Brachytherapy is also likely to be effective and carries less rectal side effects, but slightly more urinary side effects. In the case of this patient, there is no evidence proton beam therapy will result in a superior outcome to the other alternatives offered by the Health Plan. Furthermore, the side effects resulting from proton beam therapy are similar to those associated with IMRT. Thus, there is no clinical indication for proton beam therapy for treatment of this patients cancer. 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

A forty-one year-old female with metastatic Stage IV endometrial stromal sarcoma is requesting authorization and coverage for an out-on-network CT scan.Reviewers Findings:  The reviewing physician found that there is no objective evidence that CT scanning performed by the in-network radiology center is inadequate or not within the standard of care.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 60-year-old male with minimal obstructive urinary symptoms and a benign feeling enlarged prostate on digital rectal examination. The patient underwent a transrectal ultrasound-guided biopsy on 10/7/04 because he had a slightly elevated PSA in the range of 5.0 to 5.3. This biopsy demonstrated a Gleason grade 6 (3+3) prostate adenocarcinoma in less than 5% of the tissue from the left side only. Thus, the staging is considered T1c for the patients prostate adenocarcinoma. The patient has requested that he be treated with a robotic-assisted laparoscopic prostatectomy. The Health Plan has denied this request indicating that a robotic-assisted laparoscopic prostatectomy is not medically necessary. The Health Plans denial should be upheld. To date, there is insufficient peer-reviewed medical literature demonstrating that robotic-assisted laparoscopic prostatectomy results in clinically superior outcomes. As such, the requested procedure is not medically indicated. Other appropriate surgical options exist for treatment of the patients condition. 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 60-year-old female with a maternal grandmother with colon cancer and a father with colon cancer. She is otherwise asymptomatic. The patient has requested authorization and coverage for a colonoscopy. The Health Plan has denied the request on the basis that the requested colonoscopy is not medically necessary for evaluation of the patients medical condition. Based upon the information provided, it appears the patient has never undergone endoscopic evaluation. She has a first-degree and a second-degree relative with colon cancer. For persons with a single first-degree relative diagnosed with colorectal cancer at age 50 or older, there is approximately a two times greater risk of colon cancer than that observed in the general population. Furthermore, the risk for colon cancer at age 40 for such persons is the same as the risk in the general population at age 50. Thus, in this risk group screening should begin at age 40 rather than age 50. The patient meets medical necessity criteria for a colonoscopy. Therefore, I have determined that the requested colonoscopy is medically necessary for evaluation 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 35-year-old woman who has had generalized psoriasis involving 75% of her body surface including her face. Treatment with topical corticosteroids Dovonex and Tazorac has been ineffective. The patient and her dermatologist have requested coverage for Enbrel because the patient is of childbearing age. The Health Plan had denied coverage for Enbrel on the basis it is not medically necessary for treatment of the patients condition. Enbrel is the only medically necessary and reasonable treatment for this patients extensive psoriasis. Methotrexate and Soriatane are category X drugs and should not be used during pregnancy. Women using Soriatane should not get pregnant for three years after cessation of the drug. Cyclosporine is a medication to be used for severe acute generalized psoriasis, not long-standing psoriasis. It must be stopped after six months because of the high incidence of kidney damage. Methotrexate has more frequent and serious side effects than Enbrel. Because Enbrel has a short half-life, it can be stopped when the patient becomes pregnant with safety for mother and child. As such, use of Enbrel is medically appropriate and indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 34-year-old male with multiple neurofibromatosis with associated chronic pain. The patient is status post multiple surgeries and is recalcitrant to several medications and injection therapies. The patients provider indicates the patient has been tried on Actiq and has obtained significant relief. The Health Plan has denied coverage for Actiq on the basis it is not medically indicated for treatment of the patients condition. Although Actiq is used primarily in the treatment of cancer pain, it is also used for patients with severe pain due to other organic etiologies that are recalcitrant to multiple attempts with standard therapies and medications. This patient has demonstrated ineffectiveness of multiple treatment options including injections and several narcotic medications. Actiq appears to have been significantly better than other available therapies for treatment of this patients pain and therefore, should be authorized. Accordingly, I have determined that the requested medication 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 52-year-old female who experiences daytime somnolence and depression. The patient has been diagnosed with idiopathic central nervous system hypersomnolence. The patients provider indicates the patients symptoms have been well controlled with Provigil. The Health Plan has denied coverage for Provigil on the basis it is not medically necessary for treatment of the patients medical condition. Based upon the clinical information provided, it appears that drugs aimed at treatment of depression are indicated for the patient. Patients who are depressed frequently exhibit daytime somnolence even without drugs. The clinical evidence provided does not demonstrate the patient has narcolepsy or other conditions for which Provigil is indicated. In addition to an antidepressant, an active exercise program may be beneficial. In any event, there is insufficient clinical evidence supporting the use of Provigil in this case. Accordingly, I have determined that 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: Upheld Decision of Health Plan

The patient is a 38-year-old female who underwent total knee replacement in December 2003. She received extensive physical therapy throughout much of 2004. Her Health Plan has determined physical therapy was no longer medically necessary as of 6/24/04. The patient is seeking reimbursement for physical therapy she received from 6/24/04 to 10/8/04. The patients physical therapy note from 6/21/04 documents active flexion of 115 degrees with extension of 0 degrees. The patient was independent on six inch stairs and her overall function was not to be very good. At that time, the goal of continued physical therapy was adding strength for the patients overall activities. Physical therapy notes from 8/11/04 and 9/7/04 do not show any improvement in the patients range of motion in extension or flexion. In addition, there is objective documentation to confirm increased strength. Additional records from June 2004 indicate the patient was walking smoothly and was back to work with no problems. Based upon the above information, it is evident the patient could have safely moved to a home exercise/therapy program as of 6/24/04. 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.