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

The patient is a 59-year-old female with a long-standing history of alcohol dependence and depression, drinking approximately two bottles of wine and four vodka mixed drinks each night for the past two and a half years, to the point of blacking out every night for the three months prior to admission to residential treatment on 7/27/04. The patient related the increased drinking to an increasing level of depression, which was related to a series of losses. These included her mothers decline and death from Alzheimers disease, loss of some friends, an extremely stressful job, and living by herself. She was previously treated on an outpatient basis with Paxil 20mg with little perceived benefit. Pertinent social history otherwise included her emanating from a family in which her father was strongly alcohol dependent, and the patient having been married and divorced three times, with no children, and no longer involved in any intimate relationship. Upon admission to residential treatment, she was noted as depressed and affectively blunted. Her Paxil was increased to 40mg and trazodone was eventually added for sleep continuity disturbance. She was also treated with a number of therapies, appearing quite motivated for the program and without any particular withdrawal related symptoms. On 8/2/04, she was noted as affectively neutral and on 8/8/04, she conceded that she was very guarded all her life. On 8/13/04, her psychiatrist noted her as still anxious about not having a very detailed and concrete plan for her recovery.  However, by 8/15/04 she was noted as cheerful and bright and the remaining notes in her chart consistently point to her as such in mood and in affect. The patient remained in the chemical dependency treatment program until 8/27/04 and is seeking reimbursement for her stay. The Health Plan has denied coverage for chemical dependency treatment services from 7/31/04 through 8/27/04 indicating the patient could have been treated at a less intense level of care.The submitted records demonstrate the patients alcohol consumption was not only quite excessive on a daily basis for some years but was attendant with an increasing frequency of blackouts. All of this, superimposed on a highly avoidant character structure, would support the notion of her warranting residential treatment. Clearly, the patient did not have a great many immediate social supports to help her rein in her drinking and, in fact, she has tended to ward off connections with others. As such, outpatient treatment was not likely to be as effective as removing her from that environment, into one that was alcohol-free. As such, residential treatment was medically warranted. At the same time, the patient appears to have consistently brightened by 8/15/04 such that transfer thereafter to partial hospitalization would have been appropriate. Hence, I have determined that chemical dependency treatment services were medically necessary for treatment of the patients medical condition through 8/15/04. Accordingly, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 47-year-old female who underwent gastric bypass approximately two years ago. She has since lost 85 pounds. The patient indicates she has excess abdominal skin resulting in episodes of skin irritation and she is at risk for skin infections. Therefore, the patient has requested authorization and coverage for an abdominoplasty. The Health Plan indicates the submitted information does not demonstrate an abdominoplasty is medically necessary.The patient wishes to undergo an abdominoplasty to reduce the risk of skin irritation that could lead to infection. There is no evidence of infection or inflammation in the skin folds on the consultative examination. Further, the photographs submitted show excess skin, but not to the extent necessitating surgery. Conservative medical therapy is appropriate for management of this 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: Upheld Decision of Health Plan

The patient is a 48-year-old female who is seeking revision of multiple abdominal scars. She has been seen by her primary care physician, gynecologist, and plastic surgeon. The patient indicates her scars are disfiguring and her cholecystectomy scar itches a great deal with intervals of pain and numbness. She has requested authorization for scar revision of all of her abdominal scars. The Health Plan has determined the requested surgery is not medically necessary.The submitted photographs of the patients scars have been reviewed as well as medical records from her primary care physician, gynecologist, and plastic surgeon. The submitted evidence demonstrates the patient is an obese female with several large but normal scars on the abdomen. There is no conclusive evidence the scars are causing pain or functional problems. Therefore, I have determined that the requested surgery 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 48-year-old female who has requested authorization and coverage for a myomectomy. The patient has a history of abnormal uterine bleeding since January 2004. A pelvic sonogram showed three uterine fibroids measuring 14mm, 2.5cm, and 3.3cm. The patient had a negative endometrial biopsy and a negative hysteroscopy. The submitted records indicate she has had no dysmenorrhea or dyspareunia. A complaint of pelvic pain was felt to be due to a neurological cause. Her hemoglobin was normal. The Health Plan has denied coverage for a myomectomy indicating it is not medically necessary for treatment of the patients uterine fibroids.Essentially, the patient has asymptomatic uterine fibroids, which are very small. This is not an indication for surgery. The patient indicates she wishes to preserve her future fertility and has requested a myomectomy. A myomectomy is not clinically indicated in this case.  If, hypothetically, a myomectomy was scheduled, the patient would have to sign a consent allowing a hysterectomy to be performed if there was excessive bleeding, which occurs not infrequently during the requested procedure. Also, pelvic adhesions could result from the surgery, which can cause infertility. Therefore, the treatment of these uterine fibroids by surgery could have deleterious effects.It would appear a 48-year-old with irregular bleeding might have dysfunctional uterine bleeding due to fluctuating hormonal levels. When the patients estrogen levels decrease during menopause the existing fibroids may shrink in size. The standard of practice for patients such as this patient are oral contraceptives, progesterone, Lupron, and perhaps endometrial ablation. A myomectomy is not clinically indicated for treatment of the patients condition.Based upon the information set forth above, 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: Upheld Decision of Health Plan

The patient is a 54-year-old male who has a history of left knee pain resulting from slipping on wet pavement. He was assessed as having a mild medial collateral ligament strain of the meniscus. Apparently, the patient cannot tolerate anti-inflammatories and so ice and a custom knee brace were recommended by his physician. The Health Plan has denied coverage for the knee brace indicating a custom knee brace is not medically necessary.The patient has a history of knee pain, but no history of documented instability or weakness on a clinical exam that would require or benefit from a brace. As such, there is no objective evidence demonstrating the medical necessity of a knee brace. A consultation with an orthopedist, as recommended by the Health Plan, is in order to determine the etiology of the pain and course of treatment and is a more clinically appropriate alternative. Therefore, I have determined that 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 an eight-year-old male who has been diagnosed as having attention deficit disorder (ADD) and anxiety. The patient has been treated with psychostimulants including Dexedrine and Strattera, and with Provigil since 2004. Dexedrine was discontinued due to side effects, details of which are not provided, and Strattera was discontinued due to non-effectiveness. The patient has undergone SPECT imaging, and has been treated with Provigil since August 2004 with success. The Health Plan has denied authorization and coverage for Provigil on the basis it is not medically necessary for treatment of the patients condition.Review of the pertinent literature concerning the use of Provigil and ADD reveals Provigil is not indicated for children under 16 years of age at this point in time. There are no studies demonstrating its efficacy in ADD, and the off-label use of Provigil for treatment of an eight-year-old patient is not considered standard of care by most practicing child and adolescent physicians in the United States.Furthermore, the attempt to explain the rationale for Provigil in ADD due to frontal lobe findings (hypofrontality) is not specific to ADD; it is a very vague, non-specific finding, which has been observed in a variety of psychiatric disorders. With regard to the SPECT findings of a ring of fire pattern, the SPECT is not considered a prerequisite for the diagnosis. SPECT findings are still investigational and are not widely used in the medical community. Thus, at this point the use of Provigil for ADD in an eight-year-old patient is not considered the standard of care and is not medically necessary. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This patient is a six-year-old male who was diagnosed in 2002 with autism. He received weekly social skills group therapy from January 2003 to June 2004, which was covered by the Health Plan. Since September 2004 the patient has been receiving social skills group therapy through Developmental Pathways for Kids. The patients parents have requested authorization and coverage for social skills group therapy. The Health Plan has denied the request on the basis the requested therapy is not medically necessary for treatment of the patients medical condition. In reviewing the submitted literature, the specific therapy concept as developed by Dr. Wolfberg is supported by retrospective or case-control studies that are of small scale, one of which was a masters thesis presentation. None of the articles provided demonstrate social skills group therapy for autism is equal or superior to standard therapy or educational training. Additionally, these therapies have historically been included as part of the students school curriculum through the IEP program. As such, the alternative recommended by the Health Plan is an acceptable alternative and is appropriate for treatment of the patients condition. Therefore, I have determined the requested therapy is not medically necessary. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a nine-year-old male who has been diagnosed as autistic and depressed. The patients parent indicates the patient has benefited from treatment with Celexa. The patients parent reports the patient is more aggressive on generic drugs. The Health Plan indicates there is no evidence Celexa is medically necessary for the patient.At issue is the brand name Celexa versus generic citalopram for treatment of a nine-year-old male. Though the patients parent indicates citalopram has not been effective, there is no documented evidence a higher dose (+10 mg/d) of citalopram has been tried to see if the patient improves. Furthermore, review of the medical literature does not provide sufficient evidence of the superiority of the brand name over generic for this medication.Therefore, I have determined that the requested medication is not medically necessary for the 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 50-year-old female with ADHD and general anxiety disorder. The patients psychiatrist has proposed treatment of her general anxiety disorder with Provigil out of concern that treatment with stimulants will worsen her severe initial insomnia as well as exacerbate her general anxiety disorder. She has not been treated with antidepressants. The patient was prescribed Provigil 100mg twice daily and found that she was feeling better than I ever have, noting that her writing is better and I can concentrate a lot more. The patients intake evaluation notes she scored high on the following items: insomnia, guilt/self-blame, poor concentration, poor memory, affective instability, boredom, conduct problems, short attention span, general anxiety, incest history, chaotic relationships, headaches, irritable bowel, and TMJ. The patients provider has recommended the patient continue on Provigil. The Health Plan has denied coverage for Provigil on the basis it is not medically necessary for treatment of the patients condition.Based upon the submitted documentation, it is not clear the patient has ADHD, though there appears to be more than enough evidence to suggest that she has depression and anxiety. Furthermore, it seems presumptive to assume that her initial insomnia will necessarily be worsened with daytime stimulants, clearly the mainstay treatment for ADHD. There is no evidence the patient was actually tried on a stimulant. Moreover, given the patients depressive symptoms, it seems a proper course of an antidepressant for depression per se, or perhaps a course of atomoxetine would be in order. Finally, there is not yet a single, double-blinded study to support Provigil as a treatment for ADHD.  For these reasons, 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: Overturned Decision of Health Plan

The patient is a nine-year-old male with speech delay including both an expressive and receptive language delay. He began speech therapy for the speech delay in 1998. At that time he possessed 50 words, but did not use them in spontaneous speech. He was able to follow single stage duration with motoric response and could identify body parts. He showed good progress in language skills. The Health Plan provided coverage for speech therapy until December 2003. The patients parent has requested reimbursement for speech therapy services the patient received through July 2004.Review of the submitted clinical information including the November 2003 and April 2004 treatment goals reveals the patients treatment goals have in fact been advanced. The November 2003 goals indicate the patient will recall information from a paragraph. The April 2004 goals state the patient will recall information from a story. Recall from a paragraph versus a story is in fact different and shows a logical step in goals. The articulation goal is also different, comparing isolated sounds to using sounds in a sentence. Additionally, the daily progress notes reveal the patient was making progress with both the receptive language and articulation goals. The notes do not document achievement of recall in a story, but document 90% recall in a paragraph. The patient did achieve the articulation goal as documented in May 2004.Given that the patients therapist provided appropriate goals and documented gains in these goals, I have determined that the services at issue were medically 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 33-year-old female who has a long history of back pain. The patient also began experiencing neck and shoulder pain in January 2004. The patient indicates she has benefited from facet nerve block injections. The patients provider has recommended the patient receive additional facet nerve block injections for pain relief. The Health Plan has denied the request on the basis the requested injections are not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. Chronic facet nerve blocks are not the community or national standard of care for treatment of patients such as this patient. There are other more appropriate treatment modalities for this patients condition including radiofrequency ablation. Continued facet nerve blocks are not likely to be effective and are not medically indicated. Therefore, I have determined that the requested injections 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 51-year-old female with asthma. She was diagnosed with allergic bronchopulmonary aspergillosis (ABPA), which is characterized by an allergic reaction to aspergillus antigens, asthma, proximal bronchiectasis, infiltrates, elevated IgE levels, eosinophilia, serum precipitating antibodies to aspergillus and skin test to aspergillus. The patient has been on Sporanox for many years and has requested authorization for continued treatment with Sporanox. The Health Plan has determined Sporanox is not medically necessary for the patient.Steroids are the mainstay of treatment of ABPA. Treatment with anti-fungal agents is also indicated. The length of treatment if Sporanox is used as the antifungal agent is approximately 12 months. There are studies of use from one month to 20 months. The patient was diagnosed with ABPA in 1992. She has been treated with Sporanox since the time of diagnosis, approximately 13 years. Lifetime use of Sporanox for ABPA is not clinically indicated. Moreover, the patient requires no further treatment with Sporanox. Therefore, 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 39-year-old female with previously diagnosed Major Depression, Recurrent and Axis II pathology thought to be in the realm of Borderline. She has been treated with a combination of medications and psychotherapy. The patient received 141 sessions with her therapist from July 2001 to January 2005. She also saw several psychiatrists during this time and was eventually thought to be reasonably stabilized with a combination of Zoloft, Wellbutrin, and Neurontin. Neurontin was added to her regimen due to the concern of the therapist that the patient seemed sufficiently hypomanic to warrant a consideration of bipolar disorder, type II. In consultation with the psychiatrist, the operative diagnosis was changed. The nucleus of the patients symptoms centered on anger, often to the extent of rage, with a tendency to go off, as in yelling at her husband, often in the presence of their young daughter. Some of the rages included fantasies of wringing her husbands neck, though never actually becoming physically assaultive. She also suffered from some sleep continuity disturbances and a periodic tendency to feel suicidal, though there is no evidence of any real intent for such, rather one of the ostensible feeling of simply not wanting to wake up. The focus of therapy centered on the extent of the patients need for control and her rage, and how this played out in her marriage. The submitted notes indicate the patient never reported a suicide attempt.The patient has requested authorization and coverage for continued outpatient therapy. The Health Plan has determined continued outpatient therapy is not medically necessary for treatment of the patients condition.There is nothing in the submitted notes to support the presence of Borderline Axis II pathology. Rather, the included notes seem to point to narcissistic pathology as the source of the patients troubles. Clearly, the patient has no impairment in sense of self or any self-destructive behavior, items one would expect were the patient actually suffering from a Borderline organization. However, that she is a perfectionist, often given to rages, would seem entirely consistent with the notion of narcissism as the preeminent problem. The periodic suicidality is also quite consistent with narcissistic pathology. The patient may well also suffer from bipolar disorder, type II. Nonetheless, the tenor of the notes points to the patient faring relatively well just as often as faring angry, seemingly irrespective of therapy. If anything, the Wellbutrin seemed to provide the most benefit. The patients rage seems to run counter to the notion of fragility. All told, she appears to have had a fair course of therapy for close to four years with nothing to indicate that continued therapy would be beneficial; nor, is she precariously balanced. 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

This patient is a 16-year-old female with a history of bronchiectasis and recurrent pneumonias; however, she apparently does not have cystic fibrosis. Her provider has recommended an IPV device to help prevent widespread bronchiectasis. The information provided does not demonstrate why manual percussion and postural drainage or a flutter valve and acapella have not been effective.Although there is literature documenting the effectiveness of an IPV device in the treatment of cystic fibrosis, because this patient does not have cystic fibrosis, such evidence is not necessarily applicable to this patients condition. Furthermore, the patient should attempt manual percussion and postural drainage or a flutter valve and acapella prior to consideration of an IPV device. If the patient attempts and fails the alternative treatments listed then an IPV device should be considered. However, based upon the information provided and no evidence that the patient has attempted and failed the available alternative treatments, I have determined an IPV device is not medically necessary at this time. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a five-year-old male with a diagnosis of autism since the age of two. He has been receiving speech therapy since 2003. He has been receiving twice a week therapy from Rainbow Kids Achievement Center and once a week therapy from a private therapist since October 2003. At issue in this case is the therapy the patient received from Rainbow Kids Achievement Center from 10/10/04 to 2/10/05.Although the information provided shows some improvement in the patients speech under the regimen described above, there is no level-one evidence supporting the frequency of this patients therapy, especially given that it was individual therapy. Furthermore, the primary goals for this patient were articulation and comprehension, which are generally considered educational and not medical in nature. In fact, evidence suggests this patients needs and goals would be better served in a group setting. There is no evidence demonstrating twice a week individual speech therapy from 10/10/04 to 2/10/05 was medically necessary for this patient. Therefore, I have determined the Health Plans denial should be upheld.